Analysis And Comment Learning and teaching

What the educators are saying

BMJ 2006; 332 doi: (Published 26 January 2006) Cite this as: BMJ 2006;332:234
  1. Brian Jolly, director (brian.jolly{at}
  1. Centre for Medical and Health Sciences Education, Faculty of Medicine, Nursing and Health Sciences, Monash University, [Melbourne], Australia

    Notions of expertise must be relative

    Most doctors are regarded by their patients as experts. But what is expertise? If we knew more about it, we might be able to cultivate it more efficiently. An article summarises recent progress. Expertise can be seen as (a) a set of discrete skills, together with perspicacity about when to use each skill; (b) the application of theory and general principles; (c) critical analysis, using a framework for examining and interpreting situations or events; or (d) as a continuing interaction between analysis and action, in which experience is used to increase expertise. Universities tend to focus on (b) and (c), with a particular emphasis on creating theory, developing applicable rules, and generating knowledge. In the professions, though, where that knowledge comes from and how best it is learnt have been at the heart of major controversy.

    Within the interactive notion of expertise, a further distinction could be made between “experts,” “experienced non-experts,” and “routine experts.” Experts solve problems that increase expertise. Experienced non-experts work in environments that may offer opportunities to develop, but they stick to their familiar routines. Routine experts are comfortable in their role but may be working in an environment that does not challenge them. These notions might sound familiar to those who have worked with underperforming medical students or doctors, and they might help in redefining professional scope and extended practice. More importantly for health care, theories of expertise have often ignored social or “networked” aspects of knowhow: those sustained collaborative attempts to solve problems in which knowing how to complement other people's actions is as important as understanding the subject. True experts may need, to paraphrase Frank Lloyd Wright, “to contract the disease called humility.”

    The origins of diagnostic reasoning

    One attribute that distinguishes experts from novices is their superior knowledge. In medicine two types of knowledge contribute to this expertise: basic science knowledge and clinical knowledge. Their roles in diagnostic reasoning have been the subject of debate for 20 years. In the first of four models for this process, basic science allows rational integration of events, signs, and symptoms into a coherent explanatory mechanism underpinning diagnosis. In the second, basic and clinical knowledge exist in more or less parallel universes, each with its own principles, rules, and applications. Basic science provides post hoc explanations but contributes little to the diagnostic process. In the third, basic science has an important role in the development of clinical knowledge, but as the clinician becomes more adept the value of basic knowledge can seem to recede. This is because it becomes encapsulated in and modified by the clinician's growing clinical knowledge base and the variations in clinical presentation of what is “scientifically” the same case or problem. In the fourth model, basic science and clinical knowledge act independently in diagnostic reasoning.

    Researchers administered several tests of knowledge and clinical reasoning to general practitioners and medical students and used structural equation modelling to investigate the relation between the knowledge types and clinical reasoning. The best fit was for the second model. Notably, the two models that suggest a more direct relation between basic science and diagnosis were both found inadequate to explain the data. The researchers say that early development of clinical knowledge might be essential to form the framework in which basic science knowledge can be harnessed to promote expertise.

    A crisis in medical workforce training

    Early last year an Australian doctors' organisation held a meeting to review the state of Australian medical education. The Australian federal minister for education, science, and training attended and heard many claims and counter claims—for example, that problem based learning was eroding the students' knowledge base of disciplines such as anatomy, and that the apprenticeship system of medical education needed to be revived and supported. The minister responded by announcing a rigorous study of medical education that would examine issues raised at the conference and elsewhere. The study will look for the factors that make for success in medical education. A steering group, recognising that a double blind randomised controlled trial of many of these issues would at best be inadequate and at worst unachievable, identified three projects that might contribute valuable information.

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    Project 1 focuses on the outcomes expected of graduates completing their medical degrees and entering internship, and on the interface between undergraduate education and the needs of employers and postgraduate trainers. It will address several key questions: what knowledge, skills, and attitudes do medical graduates require to be successful as interns in Australian hospitals, both at the outset and later in their intern year; what are the implications of those requirements for undergraduate medical training; how well prepared are medical graduates for entry to internship; how can the transition from undergraduate study to internship be improved? Project 2 focuses on the outcomes from undergraduate medical education that are necessary for postgraduate specialist training. Project 3 examines models of undergraduate clinical education and how to use clinical educators or trainers effectively. Tenders for parts of the project, and results of these studies, will be posted on the website (