Expertise

In thinking about how to educate physicians, it is important to consider the end product we hope to produce. What is our vision of a well-educated physician? What would it mean to excel as a physician, and how can we best prepare medical students and residents to attain that level of performance? It is unrealistic to expect new graduates to function at the same level as physicians with decades of experience, but it would be a mistake not to launch them on a trajectory that leads to genuine expertise. First-rate physicians are not merely competent, they are experts, and we should prepare our trainees to achieve this level of excellence. In order to prepare them to function as experts, however, we must first understand what it means to be an expert. What distinguishes experts from novices, and what does it take to move from mere competence to expertise?

The word expert is drawn from the Latin root experientia, which means proof, trial, or experiment. An expert is someone who has attained a high level of understanding or proficiency as a result of a great deal of experience, and is recognized as a resource to whom other people should turn for advice. A novice, by contrast, is someone who has little or no experience. Drawn from the same Latin root as our word novel, a novice is literally new at some field of endeavor, like a medical student or resident on the first day of training. Competence comes from the Latin root competere, which means to be capable or qualified. Before novices can become experts, they must first become competent, and many of us become competent at particular tasks or fields of endeavor without ever becoming truly expert.

If we are serious about promoting expertise, genuine excellence as opposed to mere competence, than we must distinguish between two different types of educational outcomes, processes and performances. One means of academic and professional credentialing is based in processes. How many years of training has an individual completed? Where did the training take place, who were the instructors, and what enrichment opportunities were provided? Has he or she passed the requisite examinations? Such credentials provide important information about a physician, but they do not of themselves prove that the individual performs well in practice. To know professionals' level of excellence in practice, we need to observe them in practice. Frequently, if we are to make a high-quality assessment, we need an expert to do the observing.

What makes an expert truly expert? To say simply that experts are the people in a group who perform best at particular tasks is to beg the question. It is similarly unhelpful to say that experts simply know more than everyone else. Expertise is not the mere accretion of facts, nor is it merely repeated practice. Knowledge and skills can be inert. The expert not only knows a lot and can perform some tasks very well, the expert can use that knowledge and those skills to successfully negotiate new challenges. It is not merely that the expert sees all the pieces of the puzzle. The expert can see how those pieces fit together, and perhaps even combine and recombine them in novel and productive ways. The expert functions at a higher level of imaginative integration, seeing important patterns that others miss.

This higher level of integration enables the expert to perform tasks more quickly. A merely competent practitioner may have to go through a whole mental checklist, or may require hours or even days to perceive a pattern that is apparent to the expert almost instantly. In some cases, the pattern is visible only to the expert. The expert knows what is most important in a particular picture, and focuses right away on those features, whether it be a constellation of signs and symptoms or a collection of experimental results. It is not only that the expert knows the answers, but the expert knows what questions to ask. An expert radiologist knows how to interrogate a CT scan to extract the relevant information effectively and efficiently. To the expert's eye, some features are simply more interesting—that is, they offer a higher cognitive yield—than others.

The expert's ability stems in part from what cognitive psychologists have called chunking. Chunking is the ability to group multiple data together under a single coherent rubric. A novice looking at the starry night sky sees innumerable randomly situated points of light. When experts look at the same thing, they see numerous constellations, and can instantly call to mind the astronomical properties of the different stars they see. The operation of memory provides a well-known example of chunking. Most of us would have great difficulty recalling a string of 28 random numbers. If, however, those numbers happen to represent a sequence of the four phone numbers we dial most frequently, then they may become quite easy to recall. Experts are able to organize their perception and thinking in such a way that they can process large collections of information as coherent chunks.

When novices look at a patient, they do not know where to begin. What is germane to the diagnostic task at hand, and what is irrelevant? What represents a mere distractor, such as the vehicle that brought the patient to the hospital, and what is a vital bit of information, such as what the patient was doing when the symptoms began? Experts can often tell in a split second whether a particular finding is normal or abnormal, because they hone in instantly on the key distinguishing features. It is not just that they have seen dozens or hundreds or thousands of such cases, but that they have learned from those experiences to focus their attention on the features with the highest diagnostic yield. They are not merely experienced practitioners, but reflective practitioners, who have thoroughly mined their clinical experience for whatever lessons it can offer. From an educational point of view, the crucial question is whether expertise can be shared with learners, and if so, how to do it.

It is possible that there are no real shortcuts to expertise. To become a truly world-class chess player, for example, may require something on the order of

50,000 hours of chess playing. No one can sit down with a book about chess, or attend chess classes, and become an expert in several hundred or several thousand hours. Perhaps even more significant is the realization that expertise tends to be highly domain specific. Just because people become experts at chess does not mean that they will be expert mathematicians, linguists, or psychologists. Similarly, a physician who is an expert in cardiology may not perform better than average in another discipline, such as gastroenterology. Likewise, expert physicians are not necessarily good leaders, managers, or businesspeople.

Chess offers another interesting insight into expertise. It turns out that a world-class chess player can absorb a great deal of information about a chess match in a very short period of time. Shown a particular chess game in progress, an expert can often reproduce the position of most or all the pieces on the board after looking at it for only a second or so. By contrast, a novice might have great difficulty reproducing the position of more than a few pieces. However, the expert's ability is limited in a particularly revealing way. Experts can only reproduce the position of the pieces when their position represents an actual game of chess. If the pieces are randomly positioned, the expert performs little better than the novice. This indicates that expertise requires meaning. That is, the expert must understand the pieces as fitting into some larger strategic configuration if their position is to be memorable.

How could we capitalize on these insights in medical education? First, we need to focus our educational efforts in ways that highlight integrating concepts. Our aim is not to download reams of data, but to help learners locate and begin to exploit approaches that bring order to what they will see in daily practice as clinicians, scientists, and educators. Although it is important to give learners an overview of the terrain in which they will be working, we sometimes err on the side of excessive breadth, at the expense of adequate depth. There are some things that future physicians merely need to know about, and others that they genuinely need to know well. Among the latter are organizing concepts, and especially concepts with leverage, that can be put to use in many different novel situations.

When lecturing, good introductory overviews can be invaluable. What are we going to talk about here? What are the key concepts that we hope to take away from this discussion? How might these concepts prove useful in daily practice? We cannot simply transfer such concepts into the minds of learners and expect them to begin using them productively, but we can provide them problems to work on and guidance about how to get started. We can provide valuable guidance by working on the problems ourselves, and doing so "out loud," so learners can see how we approach them. Confronted with a welter of data, how does an expert set to work? What sorts of questions help to get the ball rolling? What sorts of questions prove most helpful when you get stuck? How do you avoid latching onto the first idea that comes to mind, thereby truncating the search for even better ones?

One powerful element of medical expertise is a thorough understanding of pathophysiology. A variety of seemingly disparate and unconnected symptoms, signs, physical examination findings, and laboratory results may fit together very nicely once we understand their common basis in pathophysiology. The expert is able to use extensive pathophysiological understanding to sift from a huge body of knowledge the particular ideas that are most likely to be relevant to the case at hand. None of us ever uses everything we know to solve a problem, and one of the first tasks in solving any problem is to determine which of our prior experiences offer insight. The novice must thumb through a large reference work page by page, looking for a similar example, whereas the expert is able to turn quickly to the relevant section. The expert's understanding may be likened to a handy index that organizes a much larger text.

If we take this lesson seriously,we should ensure that our evaluations of learners reflect this principle. Exams should not merely test the ability to recall specific facts, but to organize facts in larger contexts. As long as knowledge remains at the level of individual facts, it is inert. To bring it to life, we must invite learners to use that knowledge in solving problems. Suppose a patient presents with hematuria, blood in the urine. We should not merely ask for a laundry list of pathological processes that may cause hematuria. We should invite learners to begin developing ordered diagnostic hypotheses based on their understanding of pathophysiology and the facts of the particular case at hand. For example, is the bleeding painful or painless? Does the patient have an abdominal mass? Are there bacteria in the patient's urine? By using case scenarios to assess learner understanding, we encourage learners to think in ways that will serve them best in caring for patients.

Experts not only get the right answers. They also look for better questions. When a novice asks a question of an expert, the expert may do more for the novice by asking a question than by providing the answer. For example, the novice may present a choice between two different options for diagnostic testing, but the expert may, by asking a question of the novice, point out that additional history taking might render both tests unnecessary. Our ideal of expertise should not be a person who knows all the answers. Our vision should be someone who is able to pose and recognize good questions, and who knows how to go about finding out the answers. We need to foster a certain skepticism among our trainees, so that they eventually ask better questions than we have managed to ask. The future advance of medical knowledge depends on such inquisitiveness.

We should also bear in mind that expertise has its limitations. In some cases, expertise can serve as much as a barrier as a springboard. For example, experts do not always make good teachers. An expert may understand a subject so well that it is difficult to appreciate what it looks like to novices. The expert may know where the learners should be headed, but find it very difficult to discern where they are, and thus experience difficulty moving them from point A to point B. In some cases, merely competent individuals may make better educators, because they can better understand and relate to the people they are teaching. In some cases, residents may make better teachers than faculty members, and medical students may make better teachers than residents. This is not to say that experts cannot understand learners better than anyone, but only that they do not always do so.

For one thing, expertise in education itself can be quite valuable in the development of educational excellence. People who understand learning may be better equipped to teach than people who do not. The same might go for curriculum design, the development of new instructional techniques, and the assessment of learning. Although medical education clearly enjoys the services of many people who seem to be born educators, it is likely that everyone, even the best among us, could do a better job of teaching if we knew more about our students and how they learn. For those of us who are not naturally effective educators, such lessons might prove especially valuable.

We must also guard against the temptation to regard expertise in a closed-minded way that stunts further investigation and learning. Having an expert in our midst should not make the rest of us lazier. Instead, it should act as a stimulus to further improvement for us all. The expert should not push us out of the way as though we were irrelevant, but challenge us to grow and develop. The goal is not to avoid getting caught having to admit that we do not know something, but seeking out the things we do not know and investigating them. Lack of understanding, unless it is the result of incuriosity or indolence, is not a sign of weakness, but an opportunity for learning. We should encourage our learners not to cover up what they don't know, but to grab it by the tail and follow it where it leads.

If being an expert means simply having all the answers, then the search for new understanding will inevitably be seen as a sign of weakness. Somebody who has to go looking for an answer must not have them all. In fact, however, we must first recognize that we do not know before we go looking for new knowledge. An expert is not someone who has stopped learning, but someone who learns every day. One of the most characteristic features of a physician expert is the habit of learning. The moment we stop learning is the moment we begin to become extinct. Moreover, learning is one of the most fulfilling aspects of a professional career, because learning is intrinsically enjoyable and enables us to do our jobs better.

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