Developing clinical expertise - Veterinary Practice
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InFocus

Developing clinical expertise

CHRIS WHIPP presents the second part of his series on early postgraduate development

“Not only must students master a body of knowledge; they must learn to apply that knowledge to new situations and develop skills that will allow them to identify solutions to problems that may be unforeseen during their formal education.” (Schmidt and Boshuizen, 1993)

THE “fast-track” CPD programme for recent graduates from Paradigm Shift is designed to provide an individualised support package to help the transition into practice and the development of clinical expertise.

Developing clinical expertise depends upon the quantitative and qualitative development of both analytical and non analytical skills.

Critical is the development of efficient and effective habits of thinking and doing. In the past this has been largely left to chance but recent developments in the fields of cognitive psychology and coaching indicate that professional development can be consciously developed in ways not previously appreciated.

Two of the most important skill sets are those of critical reflection, the ability to accurately reflect on events without bias, and experiential learning, the ability to learn from experience and (within this context) to develop appropriate ways of thinking and doing for the future.

This is easier said than done. Figure 1 provides one representation of the path to expertise with expertise represented as a growing level of unconscious ability. Psychologically, unconscious inability and unconscious ability are comfortable either because you do not know what you do not know (blissful ignorance) or because you have confidence in your knowledge/skills base (expertise).

Psychologically, conscious inability and conscious ability can be very challenging either because you realise your own inabilities and need to decide what to do about them or because you realise you are only just in control of what is going on and fear making a mistake.

A key skill that the new graduate needs to develop is the ability to sit with the discomfort of the middle two stages, for it is here that learning can be maximised and the disadvantages of blissful ignorance and expertise avoided. More of this next month.

The field of expertise development is complex and I shall present here a much simplified picture: anyone interested in the subject is very welcome to contact me directly for further information.

Benefits

Expertise has many benefits, not least of which is the satisfaction that arises from appreciating your competence within a specified domain. In addition, there is the ability to make better decisions, faster, and with less data.

Shifting previously conscious tasks into the unconscious also frees up cognitive “space” for other functions, whether that be coping with the uncertainty of the task at hand or discussing a recent squash game with your colleagues!

Experience

“It is the daily confrontation with patient problems above all else that provides the opportunities for acquiring contextual knowledge essential to the development of expertise.” (Schmidt and Boshuizen, 1993)

Experience is crucial to the development of expertise, not just the quantity of experience but the quality of that experience and how it is processed. It is important that conscious effort goes into developing unbiased and critical thinking habits to maximise the opportunity for learning.

Deliberate practice

Deliberate practice is well recognised in a number of fields and its importance to the developing veterinary professional should not be underestimated. The psychomotor skills of surgery are an obvious example but of equal importance are the communication skills and non clinical skills of dealing with colleagues and clients.

These skills are learnable and deliberate practice should be employed more widely by the veterinary profession.

Cognition

At university we are taught to think in a linear hypothetico-deductive manner with relatively simplistic cause and effect reasoning and the strong emphasis on the recall needed to pass the finals! This changes upon graduation as real cases are dealt with and learnt from.

One area of common concern to graduates is that their information recall performance declines in the years after graduation. This is a normal phenomenon known as the intermediate effect (Schmidt et al., 1990; Schmidt and Boshuizen, 1993) and whilst it should be fought with appropriate CPD, there is also the need to learn smarter rather than just more after graduation. The burgeoning growth of medical information will, otherwise, be overwhelming.

With increasing exposure to cases it becomes possible to introduce reasoning “short-cuts” which simplify the decision-making process. As far as possible these should be proactively and collaboratively developed to minimise the inherent biases we all carry.

Pattern recognition

Repetitive exposure to cases gradually leads to a qualitative shift in the way of thinking of the developing veterinary professional. Rather than the linear analytical approach typical of the early days, the developing cognitive short-cuts allow increasing use of pattern recognition techniques which significantly reduce the processing time, and later, the amount of data needed (Schmidt et al., 1990).

As time goes by, “Illness scripts” (Schmidt et al., 1990; Aberegg et al., 2008) are developed which are prototypical descriptions of conditions that can be rapidly and even unconsciously matched against disease signs and enabling conditions to make a diagnosis. These being based upon the very individual experience of the individual to date.

This should be remembered in that recent graduates often have difficulty communicating with more senior colleagues and more senior colleagues also have difficulty explaining their decisions to recent graduates. This is understandable in that they are working from different perspectives and different knowledge structures. This can be a cause of friction when, in fact, it can be turned into an opportunity of benefit to both.

As expertise develops, uncertainty is addressed with greater confidence and the clinician will also develop case specific memories that assist accuracy especially with unusual presentations.

Sedimentation

Whilst I have described the development of expertise as a progression of stages, the situation is much more complicated in that the level of ability may vary with situation and even per individual case. Fortunately, the skills learned early in the career are not lost but rather sedimented (Schmidt and Boshuizen, 1993) below newer more advanced skills. This means both that older (slower) analytical methods can be applied when necessary (Moulton et al., 2007) and that it is really important to take control of your learning early in the postgraduate period because the habits you develop will be with you for life.

To achieve expertise, practitioners must “…choose to address the problems of their field at the upper limit of the complexity they can handle. And they must make this choice early in their career….” (Bereiter and Scardamalia, 1993)

References

Aberegg, S. K., O’Brien, J. M., Lucarelli, M. and Terry, P. B. (2008) The Search Inference Framework: A proposed strategy for novice clinical problem solving. Medical Education 42: 389-395.

Bereiter, C. and Scardmalia, M. (1993) Surpassing Ourselves: An Inquiry into the Nature and Implications of Expertise, Chicago, Open Court.

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.

Sshmidt, H. G. and Boshuizen, P. A. (1993) On Acquiring Expertise in Medicine. Educational Psychology Review 5: 205-221.

Schmidt, H. G., Norman, G. R. and Boshuizen, P. A. (1990) A cognitive Perspective on Medical Expertise: Theory&Implications. Acad Med 65: 611-621.

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