LAST month we left the story at the point where the developing veterinary surgeon had developed a moderate level of clinical expertise using non-analytical skills based on pattern recognition, “illness scripts” and specific memories of cases previously seen.
This brings significant benefits in that better decisions can be made much more quickly using less data. This is termed “efficiency” expertise and if the domain knowledge is fixed, this would be all that is required. However, life is more interesting than that!
I have already stressed the need to critically reflect on experience, to learn from it and to progress as a professional, to think about reality as it is and not as we perceive it. There is also the need to develop metacognitive (thinking about thinking) skills if we are to maximise our efficiency expertise and then go beyond this to higher levels of achievement. Here we hit the barrier of our own inbuilt biases and assumptions that are, ironically, the products of our expertise!
Default programme
Chris Agyris, the developer of the concept of single and double loop learning, proposes a default human programme (Table 2) which is inherently defensive and which, he suggests, retards learning in highly intelligent individuals (Agyris, 1991) such as vets.
Biases
The non-analytic skills of expertise also open an individual up to a number of cognitive errors based on failures of perception, failed heuristics and biases; these are collectively termed Cognitive Dispositions to Respond (CDRs). Crosskerry (2003) describes more than 30 CDRs with regard to medical diagnosis; the commoner ones are detailed in Table 3.
Johari Window
Developing clinical expertise is of limited value if the process is not “debiased” and this is really not easy for a person to do in isolation. It usually requires working with somebody, often a coach, who can support the exploration whilst still allowing the individual to have control of and take responsibility for the process.
Whilst I am sure most of us would claim to be logical, rational people, the fact is that because of our “expertise at life”, we spend much more time working with our interpretations of reality than actually observing it directly.
One useful way of representing this is for an individual to look at, and work to enlarge the open pane of their Johari Window (Figure 1). By consciously developing their view, individuals improve their perception of their reality. The greatest gains are achieved by way of shared discovery and a special type of relationship must exist for this to occur, which usually necessitates someone outside of the individual’s own practice.
Self-assessment
“Unfortunately, most individuals appear to be satisfied with a minimally acceptable level of performance and fail to provoke challenges by reflecting on their performance.” (Guest et al., 2001).
One of the main reasons for trying to see things as they really are is that, in general, humans are very poor at self-assessment. By working with interpretations based on assumptions, past experiences or biases we often conceive of a world much worse (or better) than it is.
Two examples spring to mind. The first is the new graduate, fresh out of college and almost certainly more intelligent, better trained and more knowledgeable than those of us were in years gone by. Despite this, many young graduates have serious and unnecessary confidence issues because they severely underestimate their capabilities and resilience.
This was one of the key reasons why the Paradigm-Shift “Fast Track” CPD programme for recent graduates was developed. Less common is the 25- plus years’ qualified practitioner who has developed efficiency expertise in the early years which has seen him or her through for many years but, having not kept up with new knowledge/CPD, serious gaps have developed.
It is not that these people are lazy, ignorant or difficult, they just don’t know what they don’t know (Kruger and Dunning, 1999) and tend to substantially overestimate their own abilities. Thinking about thinking (metacognition) provides a means of dealing with both of these issues.
Life-long learning
Life-long learning has been extolled for a long time as the answer to the burgeoning volume of knowledge in recent years. Whilst this is certainly true, there is also the reality that you could spend your life on courses trying to keep up with knowledge growth but never have time to do any work!
The answer, in part, is to bring the learning into the workplace which makes sure it is relevant, motivating and more cost-effective, allowing both the employee and the employer to benefit.
That having been said, there is also the need to identify what, when and how to learn so our “efficiency” expertise needs some development. Rather than just developing and working on automatic pilot, we can use our reflective skills to identify learning opportunities and then our metacognitive skills to slow down what we are doing (Moulton et al., 2007) and to then consciously engage in the opportunity, develop a new area of expertise and then switch the automatic pilot back on until the next opportunity presents itself.
This new domain of expertise is known as “Adaptive” expertise (Mylopoulos and Woods, 2009), essentially encompassing all the core competences of efficiency expertise but also additional cognitive and metacognitive competencies. Adaptive expertise is fun and interesting, innovative and creative; it combats the fading in interest that efficiency expertise alone can cause.
The veterinary professional who progresses to this point will feel confident to approach problems as opportunities to learn, succeed and achieve true excellence in practice.
References
Agyris, C. (1991) Teaching smart people how to learn. Harvard Business Review 69: 99-109.
Crosskerry, P. (2003) The importance of cognitive errors in diagnosis and strategies to minimise them. Acad Med 78: 775-780.
Guest, C. B., Regehr, G. and Tiberius, R. G. (2001) The Lifelong Challenge of Expertise. Med Educ 35: 78-81.
Kruger, J. and Dunning, D. (1999) Unskilled and unaware of it: how difficulties in recognising one’s own incompetence lead to inflated self-assessments. J Pers Soc Psychol 77: 1,121-34.
Moulton, C. E., Regehr, G., Mylopoulus, M. and Macrae, H. (2007) Slowing Down When You Should: A new model of expert judgement. Acad Med: 82 (Suppl): 109-116.
Mylopoulus, M. and Woods, N. N. (2009) Having our cake and eating it too: seeking the best of both worlds in expertise research. Medical Education 43: 406-413.
