The Surgeon’s Expertise: A Perspective from the Expert-Performance Approach

Abstract

The emphasis on general education, problem-based training, and professional experience for the acquisition of skill, expertise, and professional achievement has varied during the history of training of professionals, such as engineers and medical doctors. As knowledge in the corresponding professional domain increased, it became clear that students had to attain a general education, such as a pre-medicine college education for doctors, before beginning their studies at their respective professional school. Following this primarily theoretical training, graduates were trained as apprentices and interns under the supervision of experienced practitioners for several years until they could earn the credentials to practice independently. Traditional models of skill and expertise (Dreyfus and Dreyfus 1986; Fitts and Posner 1967) distinguish different phases of development of performance that are consistent with the distinction between general theoretical knowledge and professional skill. The first phase of the beginner, such as a medical student, involves reasoning from basic principles and then following instructions by teachers for applying step-by-step procedures. During this phase, gross errors occur and are noticed by the teacher, or even the student, and are corrected, and subsequently decrease in frequency. With increasing opportunities for performing similar tasks, the student becomes more able to generate better outcomes faster, more smoothly and with less effort. Some researchers of expertise (Dreyfus and Dreyfus 1986) consider individuals after extensive experience in the domain to become experts, who are able to respond rapidly and intuitively. Some domains, such as driving a car, are simple and " almost all novices [beginners] can eventually reach the level we call expert " (Dreyfus and Dreyfus 1986, p. 21). In other more complex domains, such as telegraphy and chess, they argue that it may take over a decade to reach the highest levels (Simon and Chase 1973). The pioneering research on expertise by Herbert Simon and Bill Chase (1973) emphasized the improvements in performance associated with further experience in the domain and how increasingly complex patterns (or chunks) are acquired and stored in memory, providing the basis for pattern recognition to mediate rapid retrieval of appropriate actions from memory. Numerous studies in the late 1970s and early 1980s compared the performance of beginners with experts (Chi 2006; Feltovich et al. 2006). In these studies, it was common to identify experts by using peer-nomination procedures among highly experienced professionals (Elstein et al. 1978). In the latter part of the 1980s, the conception was that accumulated knowledge of a domain, followed by an extended period of professional experience, would inevitably lead to expertise and superior performance, and peer nominations became increasingly criticized (see Chap. 1). Early studies of medical diagnosis were unable to establish superior accuracy of peer-nominated best general physicians compared to a group of undistinguished physicians (Elstein et al. 1978). Similar findings were subsequently obtained for clinical psychologists, where more advanced training and longer professional experience was unrelated to their success in treating patients' problems. Reviews show that there is a surprisingly weak relation between the length of professional experience and objective performance in a wide range of domains (Ericsson 2006a; Ericsson and Lehmann 1996). For example, the accuracy of heart sound diagnosis and many types of measurable activities of nurses and general physicians do not improve as a function of professional experience, and sometimes the performance even gradually decreases as a function of years since graduation from training (Choudhry et al. 2005; Ericsson 2004; Ericsson et al. 2007). It is important to note that in the majority of these domains, there is very little immediate feedback on the success or failure of a diagnosis. Many doctors never see the final diagnosis for a patient whom they try to diagnose, and if they do eventually see the diagnosis, their memory for their initial diagnostic process is too fragmentary to help assess what they overlooked or should have done. This situation is different in surgery, where mistakes, problems, and successful outcomes are often perceived during surgery, within hours of the completed surgery, or at least the next day, so accurate timely feedback is frequently available to help surgeons to learn and improve their skills. Consequently, as one of the exceptions from this general lack of learning from experience in professional domains, surgeons with more experience (larger number of completed surgical procedures of a given type) often have been found to have significantly superior outcomes for their patients (Ericsson 2004). In response to this dissociation between superior performance and professional experience, Ericsson and Smith (1991) proposed that researchers should redirect re-search from studying socially recognized experts to studying reproducibly superior performance in a given domain.