Expertise: a Developmental Perspective on Medical Education

Have you ever watched a really skilled craftsman at work, or a sportswoman right at the top of their game, or a virtuoso musician—someone who has absolutely mastered an area of expertise? How have they learnt to do what they do? Natural ability or sheer hard work?

 

My first boss in ENT was renowned for his surgical expertise. I clearly remember my excitement at attending theatre with him for the first time. The operation was to remove a tumour that had entangled the major blood vessels of the neck.

I don’t know quite what I was expecting, but as he made the incision and started to dissect the tissues, I began to feel a major sense of anticlimax. Where were the dazzling displays of superhuman dexterity and flashing rapidity of motion? It all seemed quite pedestrian.

And then, quite suddenly, he had freed up almost all of the tumour. A bold cut with some scissors, right up on the skull base, and the operation was over. He had quickly and quietly achieved what would have taken other skilled surgeons many, many times longer. And it all appeared effortless: at every stage he had known precisely what to do next, never wasting a single movement or a single moment; each step was achieved perfectly, first time, every time; he made it look simple, although I knew that it wasn’t. And I remember thinking: “How would you ever get to be like that?”

 

The differences between expert performers and normal adults reflect a life-long period of deliberate effort to improve performance in a specific domain

Anders Ericsson

There is a widely held conception of expertise, the heroic view, that focuses on innate talent and natural ability: individuals who are born to greatness. You’ve either got it, or you haven’t. After decades of studying expertise and expert performance, Anders Ericsson, takes the opposite view: expertise is always developed not discovered. You cannot become an expert without repetitive practice: lots and lots of it. But just putting in the time—ten thousand hours—is not enough. You have to have the right conditions, or all that practice will achieve very little. Ericsson calls practice under these conditions, deliberate practice.

In my last post I explored the Transmission Perspective on education, where a trainee learns directly from a trainer. In deliberate practice, the locus of learning shifts to the interaction between a student and their material practice. I’ve illustrated this change in a picture adapted from Daniel Pratt’s Developmental Perspective. This paradigm transforms the way that we think about the roles of both teacher and student.

Practice itself—whether simulated or clinical—provides a rich soil for the student’s roots to grow into, and vital nutrients for healthy learning. The teacher takes a more peripheral role: as a coach their responsibility is to modulate the conditions of practice, ensuring the best possible environment for growth. They can have a huge influence on learning, but they are not its primary source. Their sphere of subject knowledge may be larger than the student’s, but not necessarily. Their claim to credibility resides in what Pratt calls bridging knowledge: their ability to enable the student to get the very most out of their practice time.

Eventually, the student’s expertise may easily outgrow that of their coach; their spheres will overlap, but the learner’s may have been shaped differently, and may in fact contain an entirely different take on expertise. Think of a top tennis coach: nobody expects them to be able to beat their player in a match, but they know how to draw out the player’s full potential, through practice.

Motivation is central to the whole process. Richard Ryan and Edward Deci argue that it is useful to divide motivation into different categories. Clearly a student who lacks motivation will not engage with practice, and will not learn; but equally, attempts to produce external motivation—with rewards or punishments—will produce only superficial compliance.

 

Internalization and integration are the processes through which extrinsically motivated behaviors become more self-determined.

Richard Ryan and Edward Deci

The coach looks for ways to inspire the self-determined, intrinsic motivation required for sustained, deliberate practice: sharing approval from respected individuals; facilitating a better understanding of the ultimate goals of practice; highlighting congruence between these goals and the student’s own values; and most powerfully, helping them to discover the enjoyment and satisfaction inherent in the activity.

 

Praising students for their intelligence, then, hands them not motivation and resilience but a fixed mind-set with all its vulnerability. In contrast, effort or “process” praise (praise for engagement, perseverance, strategies, improvement, and the like) fosters hardy motivation.

Carole Dweck

In Mindset, Carol Dweck argues that a belief in the innate model of expertise—what she calls a fixed mindset—severely inhibits our ability to learn: the slightest setback becomes an indicator of unsuitability for the task at hand. Instead, the coach should encourage a growth mindset that views expertise as a learned phenomenon, focuses on curiosity and sees mistakes as opportunities for growth. In particular, they should praise effort, not results.

The student will gain most from their practice time when they have a clearly defined immediate goal for each repetition; the coach helps them to identify appropriate areas of focus for every practice session.

There are two vital nutrients which the student can imbibe directly from their practice: feedback and challenge. In a Transmission Perspective, feedback is a judgement that the trainer gives, often during the trainee’s performance. From a Developmental Perspective, the situation is more complex: while a coach is one source of feedback (augmented feedback) much more is available from the task itself (intrinsic feedback); the student needs better knowledge of results as well as knowledge of performance; and while augmented feedback may be given during an activity (synchronously) this may hinder learning—it is often more effective when received afterwards (asynchronously).

The coach ensures that the student is open to all these different forms of feedback and so enables optimal growth. Task intrinsic feedback is often ignored by students but is particularly valuable. When operating on the ear, I encourage junior surgeons to pay attention to delicate colour shifts, subtle singing from the drill and the overheated smell of unhappy bone.

 

[Flow is] being completely involved in an activity for its own sake. The ego falls away. Time flies. Every action, movement, and thought follows inevitably from the previous one, like playing jazz. Your whole being is involved, and you’re using your skills to the utmost.

Mihaly Csikszentmihalyi

Matching the challenge level of the task to the capabilities of the individual is also a vital role for the coach. In Finding Flow, Mihaly Csikszentmihalyi proposes that the optimal matching for expert performance achieves what he terms flow: an enjoyable, effortless state of being in the zone, totally engaged but not overwhelmed. For deliberate practice, a slightly higher level of challenge is needed, creating an effortful experience. The coach can support the student—scaffold their entry into this so-called zone of proximal development—to help them achieve these higher levels of arousal without tipping over into counterproductive anxiety.

 

If I miss one day of practice, I notice it. If I miss two days, the critics notice it. If I miss three days, the audience notices it.

Jan Paderewski (pianist)

Finally the coach needs to communicate the need for ongoing practice, however experienced their student. Carl Bereiter and Marlene Scardamalia write about the concept of adaptive expertise. For them expertise is not an endpoint but a lifelong journey. An expert performer needs to constantly practice or their skill level will diminish.