Expert and expertise: meanings and perspectives

Abstract

The attention given to the development of expertise by researchers into professional learning has been steadily growing in the health sector and is beginning to be extended into other sectors. Simultaneously, perhaps independently, the range of meanings accorded to the words ‘expertise’ and ‘expert’ has been widening. It is a good time to clarify and review some of the disparate strands of meaning. The term ‘expert’ comes from the Latin adjective expertus, the past participle of the verb experior, which means ‘to try’ or ‘to experiment’. Hence, expertus literally meant ‘to have tried’ or ‘to have experienced’. However, the Shorter Oxford English Dictionary indicates that the use of ‘expert’ to mean ‘experienced’ is now obsolete. Instead we find that the adjective ‘expert’ now means ‘trained by practice’ or ‘skilled’; and the noun ‘expert’ carries the additional meaning: ‘One whose special knowledge causes him to be an authority’ or ‘a specialist’. ‘Expertise’ is defined as ‘expert opinion or knowledge’ or ‘the quality or state of being an expert’. This implies that experience alone is not enough; there has to be an appropriate learning outcome. There is also a suggestion of a social process (training) and a social role (an authority). Becoming an expert entails not only learning, but socialization. Has the word ‘expert’ become synonymous with the word ‘professional’? The origins of the professions are closely linked to claims for special knowledge, but many social and economic factors were also operating. The need for professionals to be trustworthy related to confidentiality as well as to competence; no-one, especially the powerful, wanted conversations with their doctor or lawyer to be leaked. Moreover, the reputations of many professionals depended mainly on the prestige of their clients and/or the person or organization that trained them. The association of specialist knowledge with universities did not start until the mid-19th century for doctors and until the last third of the 20th century for other health and social care professions. Its early effect was usually to exacerbate the tension between formally codified knowledge, specialist knowledge acquired by experience and a broader understanding of people, organizations and the ways of the world. Today, however, the specialist knowledge base of ‘so-called experts’ has been increasingly challenged. The cynical definition of an expert is a person who has learned ‘more and more about less and less’ and is generally ‘out of touch with the real world’. There is also considerable scepticism about the claim that experts prioritize the interests of their clients. This is exacerbated in the public sector, when the customer is increasingly seen as the State, and in the private sector when the ‘real customer’ is the client's employer or insurance company. Within the professions, career progression depends, to a significant extent, on the opportunities for learning and social networking provided by one's job, because both of these factors will affect one's chances of getting the next job. Another issue arises when career progression involves taking more and more management responsibilities and thus limits the possibility for developing further expertise in the professional role. Medicine, law, information technology and the more research-based universities appear to be the main exceptions to this trend, but the situation is changing in healthcare with the introduction of new ‘advanced practitioner’ or ‘consultant’ posts for nurses and several other health-related professions. Two contrasting further uses of the term ‘expert’ are the ‘expert witness’ and the ‘expert patient’. The expert witness is called to give evidence to a court or public inquiry because of their specialist knowledge. However, their role is to advocate a particular view of the subject of the inquiry and they will also have been chosen for that purpose. They expect to be cross-examined and may be preceded or followed by another expert chosen for having a different opinion. The main difference from a purely academic debate is that it is the non-experts who have to be convinced by the expert's testimony. They also have to give their evidence and answer questions according to the procedures and nuances of that particular inquiry. This requires a form of communication that may be unfamiliar and will probably improve with practice, provided it is good enough to be asked again! Over time they will become expert at being an expert witness, and then they may be asked to give witness on matters at, or even beyond, the boundary of their zone of expertise, when another expert would be more appropriate. Not all professional witnesses resist such challenges to their professional integrity. In many organizations, some people get more opportunities to be heard than others because of their good communications with managers and clients, and become regular ‘internal expert witnesses’. The concept of the ‘expert patient’ was the subject of a UK government publication (DoH 2001). This recognizes two types of expertise in patients with chronic and/or life-threatening conditions. The first is the patient's knowledge of their own symptoms and awareness of lifestyle factors that might affect those conditions. Thus, many patients are experts in their own health, and even if they do not consider themselves as experts, practitioners may still want to use their current understanding of their illness as their preferred starting point for any consultation or advice. Without the patient's agreement and at least partial understanding, the prescribed treatment plan is unlikely to be followed. Most important of all is the purpose of the treatment. What priority does the patient give to various aspects of their current and future lifestyle? The professionals need to be able to advise on the likelihood of possible outcomes for this particular patient, but only the patient can ascribe relative values to those outcomes. The second type of expertise is constructed by patient-user groups, who pool their experiences and knowledge of their condition and provide advice to others over the internet, as well as acting as advocates for enhancing the capacity and capability of professionals and healthcare organizations to support patients who suffer from that particular condition. In general, client expectations in healthcare have grown so rapidly that it is difficult to imagine many experts being accepted by the majority of their clients without also being good communicators and well disposed towards sharing information and, equally important, uncertainty. Focusing on patients draws our attention to the problems posed by the individualistic character of the term ‘expert’. Advocates of multiprofessional approaches to practice rightly argue that several professions and/or specialties within professions have expertise relevant to patients with complex, multiple conditions, and such cases take up an increasing proportion of the professional time provided by health and social care services, as the population grows older. Hence, the most capable healthcare teams will need members from several different professions, who have acquired expertise in recognizing each other's expertise and working together with, and in the interests of, their patients. It is difficult to see how this can be achieved without a much wider understanding of the nature of different types of professional knowledge. Kennedy's (1987) review of professional expertise put forward four definitions, each based on a different view about how expertise influences professional actions. She starts with the notion of expertise as a set of discrete technical skills, noting both the additional need for expertise in deciding whether and when to use each skill and the disastrous consequences of neglecting the development of such skills. She then rebounds into a contrasting definition of expertise as the application of theory and general principles, noting that not all such principles are scientific, some being derived from social norms. She avoids the temptation to equate these first two definitions to practice and theory, and challenges the assumption that theory and general principles can be applied to particular situations by asking how the practitioner can: • Recognize a particular case as an example of a general principle, • Adjust predictions derived from a general principle to accommodate the special features of the case, and • Blend the variety of potentially important principles to form an integrated body of knowledge that can be applied to specific cases. (Kennedy 1987, pp. 139–140) Her conclusion (p. 142) is that: The general-principles definition of expertise eventually stumbles on the same problem that besets expertise-as-technical-skill: principles provide rules of thumb intended to guide practice, but there are no rules of thumb for how to select the appropriate rule of thumb. Case do not present themselves to practitioners as examples of general principles, but instead force practitioners to ferret out the principles from the case. Further, there are no rules for altering the general principle to take into account particular circumstances, and there are cases for which several equally plausible principles may apply, so that practitioners must decide which principle(s) will be applied and which will not. Finally, there is evidence that the heuristics human beings use to determine which principle applies, and to decide whether to apply it or alter it, may be biased or inaccurate. Kennedy's third definition, expertise as critical analysis, prescribes neither techniques nor principles but ‘a paradigm for examining and interpreting situations’. The problems with this definition are, first, that good arguments do not necessarily lead to good decisions and, second, that the available evidence is often insufficient to support the kind of analysis that most proponents of approaches, such as evidence-based practice, tend to expect. She argues that while pure analyses may satisfy technical or economic rationalities, they do not resolve social, organizational or political issues. Codified knowledge of relevant principles, concepts and theories is also needed for professionals to become able ‘to view cases from any perspective other than that of their paradigm’. Her fourth definition, expertise as deliberative action, assumes ‘an interactive relationship between analysis and action, such that each influences the other.… Expertise evolves and develops with experience, but that experience can only contribute to expertise if practitioners are capable of learning from it’ (ibid, p. 148). Expertise cannot be assumed to develop automatically through years of service. Thus, the job of those who support the development of expertise at any stage in their career is to ensure that they are both capable of, and disposed to, critically examining their own actions and the consequences of those actions. Codified general principles are still important, but ‘their role is interpretative rather than prescriptive’. Deliberative decision-making, as characterized by Schon (1983), begins with practitioners imposing an interpretative framework that defines the situation in a way that enables them to draw on their previous experience. However, this usually assumes a certain type of solution, so the practitioner has to envision the consequences of such a solution and evaluate them ‘both against his or her definition of the problem and against other criteria of satisfactoriness that derive from other goals.… If the consequences are unsatisfactory, the practitioner reviews the original framing of the situation, surfaces the theory implicit in it, tries to see what was wrong with it, and finally redefines the situation in another way, in search of a better solution’ (ibid, p. 148). Difficulties may arise, however, when the practitioner focuses on the surface features of the problem, usually some aspect of its content, and neglects its underlying structure; and/or when the natural tendency to use information for confirmation rather than disconfirmation prevents him or her from discovering their mistake. ‘The important intellectual task of deliberate action is not problem solving – the weighing of alternatives to reach a predetermined end – but instead is problem setting, where goals, means and ends are all weighed together’ (ibid, p. 150). However, this kind of deliberative action ‘permits goals as well as means to vary across situations, thus minimizing the role of standards of accountability’ (ibid, p. 153). This can only be redressed by full consultation with patients, and an audit system that is sensitive to social and ethical issues. Kennedy (1987) concludes that: None of the four definitions is self-sufficient. All four definitions make a significant contribution to professional expertise. Expertise is always fallible. Higher Education outside the professions tends to focus on the second and third definitions, with an increasing emphasis on knowledge creation as well as interpretation at the postgraduate and faculty levels. Before addressing this creative dimension, however, I want to introduce the contrasting perspectives of the cognitive sciences and socio-cultural theory. In the early 1980s, the increasing sophistication of computers led to a series of attempts to design computer-based ‘expert systems’ that could tackle problems hitherto assigned to human experts. A series of disappointments drew attention to the lack of understanding of the human expertise that they were hoping to simulate or outperform, and this led to the realization that human expertise was mainly developed through problem solving at work. The concept of expertise developed by cognitive scientists during the 1980s was that of ‘a well-organized body of accessible and useful domain-specific knowledge, which an agent draws upon and adds to, in effectively solving complex problems’ (Hakkarainen et al. 2004). Although some studies of expertise have focused on agents who are acknowledged experts in their fields, expertise is generally understood as ‘an individual actor's actual cognitive competence, drawn upon in effective problem solving, regardless of his or her formal education or position in an organization’ (ibid p. 19). This rediscovery of the importance of domain-specific knowledge was boosted, if not triggered, by two decades of research into medical diagnosis based on expert–novice comparisons. These found that reasoning skills tended to peak by the final year of medical school, and so did recall of most domain-specific facts and concepts. The main distinguishing feature of experts was their superior organization of the relevant knowledge, which enabled them to make relevant inferences and recognize patterns that gave them clues to possible answers which could then be tested against the full evidence. This was accompanied by the gradual encapsulation of biomedical concepts within a purely clinical discourse (Boshuizen & Schmidt 2000). However, the experts in these research studies were still able to recall and use biomedical concepts when asked to do so, suggesting that these concepts were still needed by them for use in more complex cases than those used in the research. Another approach to decision making is provided by Rasmussen's (1986) theory of process control. He distinguished between responses to new situations at the skill level, rule level and knowledge level. Alhough not happy with this use of these particular terms, Eraut et al. (1995) independently developed a similar analysis when investigating nurses’ use of scientific knowledge. At the skill level, Rasmussen refers only to automated skills, which enable agents to respond almost immediately to situations they spot by pattern recognition without even stopping to think. The rule level does require agents to stop and think, but their familiarity with the situation, and experience of dealing with similar situations, leads to rule-based responses with some situation-specific adjustments. In the literature these are described as well-defined problems. The knowledge level deals with problems that are unfamiliar or ill defined and require a response that is novel to the agent(s) concerned. The key point for our discussion is that the level of use required depends on the previous experience of the agent. All problems are ill defined for novices, and learning professionals may be expected to expand their domain of well-defined problems throughout their career. Moreover, changes in the nature of their patients, in diagnostic methods or in treatments or care regimes, will inevitably come to change what counts as an appropriate solution. This analysis suggests two further definitions of expertise. One of them relates to a professional's repertoire of well-defined problems to which they can apply familiar solutions, using a rule-based approach that avoids time-consuming deliberations. The other embraces the mental skills and knowledge required for tackling ill-defined problems. These mental skills have some similarity to Kennedy's ‘critical analysis’ definition of expertise, but its workplace context moves it some way towards ‘deliberative action’. While Schon (1983) describes this expertise in terms of problem setting, reframing the problem and reflection-in-action, Kennedy hovers between the immediacy of Schon's concept of reflection and the more deliberative approach of Dewey. The idea that this involves ‘mental skills’ was introduced by Sternberg et al. (2000), who has identified a cluster of mainly tacit skills linked by a general factor that he calls ‘practical intelligence’. He cites studies from several work domains to argue that the quality of performance at work can be best explained by a combination of domain-specific content knowledge and practical intelligence. Moreover, there is very little correlation between practical intelligence and performance on the traditional cognitive ability tests used to measure IQ. This work is closely linked to the research on generic management competencies initiated by McClelland (1973) and further developed by Boyatzis (1982) and Spencer & Spencer (1993). This brings us to a rather different approach to the pathway from novice to expert, which focuses primarily on the development of tacit knowledge. The Skill Acquisition Model of Dreyfus & Dreyfus (1986) was originally developed to counter what they considered to be the over-ambitious claims of decision analysis. They describe their model, which brings together situational understanding, routinized action and decision-making, as an integrative overarching approach to professional action. It depicts progression through five levels: Novice; Advanced Beginner; Competent; Proficient; and Expert. Its early and middle stages involve the development of situational recognition and understanding, and of standard routines that enable one to cope with crowded busy contexts; the later abandonment of explicit rules and guidelines as behaviour becomes more automatic; and a peaking of the deliberative mode of cognition at the Competent stage. Progression beyond competent is then associated with the gradual replacement of deliberation by more intuitive forms of cognition. Tacit knowledge appears in three different forms: Situational understanding is being developed through all five stages, based largely on experience and gradually widening its scope. Standard, routinized procedures are developed through to the competent stage for coping with the demands of work without suffering from information overload. Some are likely to have begun as explicit procedural knowledge then become automatic and increasingly tacit through repetition, with concomitant increases in speed and productivity Increasingly, intuitive decision-making, in which not only pattern recognition but also rapid responses to developing situations

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