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What defines expertise in regional anaesthesia? An observational analysis of practice.
- Nila Cota, Allwyn M Cota (27 October 2006)
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A personal insight into regional anaesthesia: authors' response
- Andrew Smith, Dawn Goodwin, Maggie Mort and Catherine Pope (19 October 2006)
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A personal insight into regional anesthesia
- Attam J Singh (4 October 2006)
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Nila Cota , Allwyn M Cota
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Editor-We read AF Smith et al’s paper (September 2006) with great interest. We congratulate the authors for a brave attempt at qualitative science in a predominantly quantitative academy. We however wish to raise the following issues. 1) Definition of concept under scrutiny-expertise v/s competence: The authors proceed to obtain empirical data to support a conceptual difference between competence and expertise having observed that the selected trainees lacked skills in the ‘affective’ domain as compared to the Consultant. There are known definitions in literature explaining expertise and competence. Bloom(1960), Krathwohl(1964) and Dave(1975) identified levels from simple to complex in the cognitive, affective and psychomotor learning domains respectively. Competence is ‘the ability to perform tasks effectively at work’ i.e achieving a level of performance measured against an agreed standard in all the three domains. Expertise on the other hand is usually achieved by a competent person with time and exposure to different situations leading to performance at the highest levels in all three domains. This stage of learning is also known as unconscious competence. A step beyond expertise, required of a trainer is reflective competence-conscious competence of unconscious competence (David Baume 2004) 2)Methodology: It would be interesting to know whether the transcripts published were typical of all observations, and the degree of agreement. 3)Bias: Qualitative perspectives embrace Max Weber’s concept ‘verstehen’ emphasizing that validity requires intimacy in order to understand human action in terms of it’s interpretive meaning. We still feel it was not necessary for the researcher to be aware of the grade of the persons being observed. One can envisage a situation where if the authors were blinded to grade, they may find at times and different situations a Consultant does not come out as an expert, and a trainee may do so. It would then be interesting to find the proportion of times this occurs to ground any theory of what expertise means in specified areas of anaesthetic practice. Nila Cota, Allwyn Cota. Torbay Hospital, Torquay. e-mail: ancota@btinternet.com Conflict of Interest:None declared |
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Andrew Smith Royal Lancaster Infirmary, Dawn Goodwin, Maggie Mort and Catherine Pope
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We would like to thank Dr Singh for commenting on our paper. Whilst it adds to our arguments rather than criticising them, we would nevertheless like to offer the following observations. First, Dr Singh’s letter demonstrates something we have noted many times. Once anaesthetists are made aware of the tacit elements of their practice, this seems to ‘unlock’ this knowledge for others to benefit from. One other situation we have seen it is where ‘interesting cases’ are discussed – more often than not, those present are eager to share their own personal experiences and nuances of technique. In our view, anaesthetic training would be enhanced by identifying and promoting such learning opportunities [1]. Second, those trained in biomedicine may be uncomfortable with the methods and findings of qualitative research, originating as they do from the social sciences. A common criticism is that it allows the researchers to impose their own views upon the subject they are studying, thus introducing a bias which ought not to be there. Whilst we have taken a number of steps to prevent this [2], one ‘acid test’ of the validity of the account produced by such research is how it resonates with others who are ‘in the know’. Thus it is gratifying to know that our work has struck such a chord in this reader. Third, we agree on the clinical point that, whilst patient position is often specified in instructions about block insertion, the doctor’s is not. This may well contribute directly to the success of the procedure, as Dr Singh suggests, but we would also argue that it is important for the doctor to be comfortable as well as the patient. How often do we see anaesthetists bent over in awkward positions trying (often for some time) to perform a practical procedure? If the operator is relaxed and ergonomically positioned, one would expect work to flow more smoothly. But there is more to this than might meet the eye: in a related publication, Goodwin [3] analyses the spatial arrangements of anaesthetic work and its relationship to embodied knowledge. She shows how the careful positioning of practitioners, patients, tools and equipment actively shapes perception, and she discusses the implications for proficient practice. Fourth, we hope that the College’s regional anaesthesia audit will enlighten the practice of neuraxial blockade in the United Kingdom, but would question whether such an investigation can capture the rich contextual detail which our in-depth qualitative work has reported. We see the two approaches as complementary. In our view, anaesthetic practice can, and should, draw on all possible ways of understanding in its quest for continual improvement in the quality and safety of care. 1 Pope C, Smith A, Goodwin D, Mort M. Passing on tacit knowledge in anaesthesia: a qualitative study. Medical Education 2003; 37: 650-5. 2 Smith AF, Goodwin D, Mort M, Pope C. Expertise in practice: an ethnographic study exploring acquisition and use of knowledge in anaesthesia. British Journal of Anaesthesia 2003; 91: 319-28 3 Goodwin D. Upsetting the order of teamwork: is 'the same way every time' a good aspiration? Sociology (in press). Conflict of Interest:None declared |
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Attam J Singh, Anaesthetist Watford
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I read with interest the article by Smith and Pope on the definition of expertise in regional anesthesia. I found it to be an extremely important attempt at investigating the necesary skills required in performing anesthetic nerve blocks. The study was an initial investigation from which larger and more definitive studies could be made. The examples given were genuinely recognizable and could be echoed many times in my career and, I'm sure, in many hospitals around the country. With regards to what determines expertise, I would like to add a few points. The ability of the physician to gain a rapport with the patient is, I think, of utmost importance, and should be given the highest priority when delivering a nerve block. Once this is achieved, whether the block is successful, unsuccessful or even painful, you will have gained the the patient's trust and he/she will be satisfied with whatever the result. Suitable positioning of the patient is of course essential when performing regional anesthesia. However little importance is given to the doctor's own position, in particular when carrying out central nerve blocks. I have found this to my benefit on labour ward where sitting down slightly to the left of the patient helped insertion of the epidural needle with my right hand using the continous pressure technique. Another example is approaching femoral nerve blocks from the opposite side to aid stabilistion of the artery. These are very much anecdotal but should be stressed much more vigoursly when teaching the regional anesthestic to the novice. Like with any skill 'practice makes perfect', and it is the lack of practice that produces diffident and insecure anesthetists. The more they are practiced on a regular basis, the more they become ingrained in our skill-set. This could be undertaken by regular weekly teaching on the various aspects of regional anaesthesia, the mandatory possession of a manequin in the anaesthetic department and the provision of sufficient time and resources to allow trainees to attend refresher courses on regional anesthesia. As a trainee, I have found the art of regional anesthesia to be dwindling amongst my fellow colleagues as the teaching tends to be 'patchy' and complication rate high due to a lack of practice. This needs to be addressed and dealt with immediately. The national audit for central neuraxial blockade will go some way to tackling some of the qustions posed by the article but further research needs to be undertaken to expose our failings and rectify our inadequacies. Conflict of Interest:None declared |
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