Intended for healthcare professionals

Rapid response to:

Personal Views Personal views

The sins of expertness and a proposal for redemption

BMJ 2000; 320 doi: (Published 06 May 2000) Cite this as: BMJ 2000;320:1283

Rapid Response:

Expertise and power

I am heartened by David Sackett's conclusions about the role of
expertise in medicine because I agree (BMJ 2000;320:1283). Many people
who might be called experts might take the view that it is the luxury of
successful and recognised expertise to move on to other pastures. Other
observers might suggest that it is the nature of power that gaining
credibility as an expert is the ultimate
satisfaction for those who enjoy, need and exploit power - they will hold
on to power and only relinquish it under pressure.

But I would suggest we take the debate further, specifically in
relation to evidence based practice. A good definition of EBP is that
decisions are based on a variety of evidence (client data, RCT's, research
& reviews) the context (personal values, experience, education)
constraints (laws, policies, variability of evidence,time & skills
available, costs).
Practice decisions are perhaps at their best when all three of the above
overlap significantly and practitioners whether in practice or in public
health need to strike a balance of advantages and disadvantages in what is
a very complex situation.

For example the chances of increased quality of care, improved audit
patient satisfaction and cost effectiveness must, I believe be weighed
against problems and disadvantages. These include, as David Sackett
suggests, the increase in expert self satisfaction, but also an increase
in power to control patients as well as colleagues; the chances of
narrowing the focus to individual biology and
hard science perceived as more susceptible to traditional quantitative
analysis; a return to a mechanical meta-analysed host of prescriptions for
disease control.

What I suggest needs to be debated more openly is the danger that EBP
may exclude informal social influences on quality; or the real likelihood
of a growth in the new skills of critical appraisal that can somehow
overcome the pitfalls of variability of evidence.
and the huge cultural shift implied. The need for new skills might
effectively exclude many at the coal face whose problems are less to do
with applying sound evidence than coping with the results of family
breakdown, poverty and inequality.

The focus of debate must look for a balance between sound, appraised
evidence alongside an openness to user involvement, best practice,
judgement and experience. Community based as well as top down, socially
informed as well as medically inspired. To leave all in the hands of the
new world of evidence based life is, I suggest, risky!

Dr Michael Craft
Visiting Fellow in Public Health
University of Greenwich

Competing interests: No competing interests

12 May 2000
Michael Craft