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The right hand of Claude--reflections on becoming an expert

From the March 1995 ACP Observer, copyright © 1995 by the American College of Physicians.

By Frank Davidoff, MD, FACP

At the hospital in Boston where I did my residency, individual surgical residents could, in the later years of their training, elect a two-month rotation on the service of a distinguished general surgeon--Claude Welch, if I remember right. I once asked a resident who had been through that rotation what he actually did while he was on the service; he said, "During the first month I watched what Welch did with his right hand; during the second month I watched what he did with his left."

Thinking about how people learn to become truly expert, I've been increasingly impressed with the deeper meaning of that surgical resident's account. Basically, he was saying, "Even for someone who is already quite skillful, an important first step in moving to higher levels of mastery is first to break a complex skill down into its component parts. Only after you've mastered the parts separately can you begin to put them together into the finished performance."

A similar but more general model for acquiring expertise has been described based on observations in other fields (1). It starts with the acquisition of "skills-based" performance-patterns of thought and action governed by stored patterns of "pre-programmed" instructions, referred to as schemata. These schemata are reminiscent of what my surgical colleague absorbed by watching Claude Welch's right hand. This progresses into "rules-based" performance, in which solutions to familiar problems are governed by stored rules of the "if X, then Y" variety.

Ultimately, the process reaches a "knowledge-based" level of performance, or synthetic thought, which can be used for new situations requiring conscious analysis and stored knowledge. As one commentator summed up this process, "Experts are seen has having a much larger repertoire of schemata and problem-solving rules than novices, and they are formulated at a more abstract level. In one sense, expertise means seldom having to resort to knowledge-based functioning" (2).

Appropriate intensity in training

The training of experts in most fields, in medicine and elsewhere, is a high-intensity enterprise. That is to say, a great deal of learning is compressed into every day of training (and many nights as well), leaving little time or energy for anything else. This routine often continues without respite for years. As the author and commentator Alistair Cooke once remarked, what is needed, in effect, in learning to become an expert is "to get up every day and devote yourself entirely to the task at hand, over and over, until the day comes when you wake up and find yourself one of the competent ones of your generation."

Training this intense raises legitimate concerns about dehumanization and exploitation of students, but the intensity itself seems somehow connected with the idea of reaching beyond ordinary levels of achievement. It is as though experts know that students must reach a kind of "critical mass" of skill--the once-you've-learned-it-you-never-forget-it level, as when you learn to ride a bicycle--before they can cross over into the forbidden territory of high-level mastery. Creating this much-prized "critical mass" may simply require a certain level of pressure; a too leisurely pace or a too casual attitude may simply allow students to slip back too much every day, may not permit them to reach the necessary "fusion threshold." Or perhaps intensity operates at an attitudinal level, by conveying a meta-message about the extreme importance of what students are learning.

High-level training is associated with low student-faculty ratios, tailored programs or private lessons. But while it may be true that a few learners become experts entirely without being part of a group, even the surgical residents who spent two months alone with Claude Welch were very much connected to their peers the rest of the time, as are most students on the way to high-level mastery in medicine or other disciplines.

Members of the group share not only in the satisfactions of learning but also in the disappointments and the setbacks, the gripes and the black humor, its members supporting each other through the training process in all its intensity. Peers teach each other, particularly in medicine (3), and peers supply much of the excitement and enthusiasm needed to stay the course. Peer pressure also contributes a good measure of the competition, the discipline and the values attached to expert training, as well as the benchmarks against which students measure their progress (4). It is surely not an accident, then, that becoming an expert is usually at least as much a social as an individual matter.

The educator as coach

The teachers of expert-level performance also must have a unique blend of abilities: the ability to perform at a high level and the ability to reflect on performance both in themselves and in their students (5). Great performers may sometimes lack the ability to reflect, which probably explains why not all great performers are great teachers. Many concepts are associated with the image of the master teacher: professor, scholar, mentor, guru, and many of these are probably correct for disciplines that primarily involve abstract, intellectual work. For the performing professions, however-music and theater, design and dance, architecture, law, medicine-where the ability to act is as important as the ability to think, coach is probably the term that best fits the reality of the master teacher. And while coaching in the professions has begun to receive serious attention (5), the theory and practice of coaching still needs a lot of work, particularly in medicine.

The concept of coaching resonates convincingly with the four-component cycle of experiential learning described by Lewin, Dewey, Piaget and others. Kolb's synthesis of these components suggests that students learning in the "experiential" mode must be given the opportunity to:

  • involve themselves fully, openly and without bias in new experiences;
  • reflect on and observe their experiences from many perspectives;
  • create the concepts that allow them to integrate their observations into logically sound patterns, principles, theories; and
  • use these patterns, principles and theories to make decisions and solve unfamiliar problems (6).

Coaching medical residents means providing them with experience in managing a good mix of familiar and unknown problems. It involves leading them back and forth between experiences and reflection on those experiences through reading, discussion (particularly Socratic), feedback, modeling, introspection and input from a variety of disciplines. It involves helping students learn to apply "standardizing" techniques (2), that is, principles, tips, rules, such as learning to make complete and precise problem lists, to use flow sheets, algorithms, heuristics (rules of thumb) and the like. Lastly, it involves moving students along the path of graduated, increasing decision-making and responsibility.

Even the best coaching won't be effective, however, unless it happens in a setting that contains many other important features of an environment that supports learning. Many (but not all) of these features are captured in the so-called "Special Requirements" defined by the Residency Review Committee in Internal Medicine. The clinical learning environment includes the obvious physical elements such as hospital vs. outpatient or home care settings, but others, less obvious, may be just as important. Examples would include the bedside as a place for teaching in addition to the conference room; an abundance of well-organized and easily accessible information resources; and a setting that is a realistic reflection of actual practice. And then there are organizational features of the environment, including:

  • Balance between redundancy and variation of experience-enough repetition to reinforce learning, enough diversity to stimulate, teach the fine points.
  • Pacing that slows things down when residents are learning complex skills, allowing them to "concentrate on what the right hand is doing;" and speeds things up when residents are learning things that need to be done under pressure.
  • A safe climate that allows residents to experiment, to learn hard lessons from their inevitable mistakes without feeling they are bad people (4). This is critical, since one feature of expertise is making the fewest possible mistakes, and continuously learning from those mistakes (2).
  • A peer group that generally pulls together.

A certain degree of internal tension is intrinsic to coaching, since experiential learning, particularly at the expert level, requires learners increasingly to act and reflect at the same time and, as Kolb points out, it is very difficult to be concrete and still be "theoretical," all at once (6). The pedagogical challenge to coaching is great, therefore, since it requires supporting the simultaneous exercise of abilities that are polar opposites. Claude Welch was apparently a master teacher precisely because he knew how to help his residents move back and forth between actor and observer, between immediate, concrete work as his OR team assistant and analytic detachment as an active, experiential learner.

Knowing how far to push

All learning, but particularly "real world" (rather than simulated) experiential learning also requires learners to continually push the envelope, to move repeatedly out of the comfort zone of knowledge and skills already mastered. The philosopher Hegel said on this point that "Any experience that does not violate expectation is not worthy of the name experience." If, however, learners get pushed too far, they will be "left paralyzed by insecurity, incapable of effective action" (6).

Effective learning therefore requires learners to encounter many things that "rip the fabric of experience," but these rips then need somehow to be "magically" repaired, so that the learner can "face the next day a bit changed but still the same person" (6).

Looking at all this complexity, it's a wonder anyone ever learns to be an expert, but of course people do, every day. At the same time, I suppose, it wouldn't hurt if we could become more expert on how to make that happen.

Frank Davidoff is Editor of Annals of Internal Medicine.

References

1. Rasmussen J, Jensen A. Mental procedures in real-life tasks: a case study of electronic trouble-shooting. Ergonomics. 1974; 17:293-307.
2. Leape LL. Error in medicine. JAMA. 1994; 272:1851-7.
3. Mizrahi T. "Getting Rid of Patients. Contradictions in the Socialization of Physicians." Rutgers, N.J.; Rutgers University Press, 1986.
4. Bosk C. "Forgive and Remember. Managing Medical Failure." Chicago; University of Chicago Press, 1979.
5. Schön D. "Educating the Reflective Practitioner. Toward a New Design for Teaching and Learning in the Professions." San Francisco; Jossey-Bass, 1987.
6. Kolb DA. "Experiential Learning. Experience as the Source of Learning and Development." Englewood Cliffs, N.J.; PTR Prentice Hall, 1984.

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