Expert and expertise: meanings and perspectives

© 2005 Blackwell Publishing Ltd.

Learning in Health and Social Care

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Blackwell Publishing, Ltd.

Editorial

Expert and expertise: meanings and perspectives

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 synony-

mous 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 confiden-

tiality 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 ‘con-

sultant’ posts for nurses and several other health-

related professions.

174 Editorial: Expert and expertise: meanings and perspectives



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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 opin-

ion. 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 accord-

ing 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 cli-

ents, 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 advoc-

ates for enhancing the capacity and capability of

professionals and healthcare organizations to sup-

port patients who suffer from that particular condi-

tion. 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 differ-

ent types of professional knowledge.

Kennedy’s (1987) review of professional expertise

put forward four definitions, each based on a differ-

ent view about how expertise influences profes-

sional 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 con-

sequences of neglecting the development of such

skills. She then rebounds into a contrasting defini-

tion of expertise as the application of theory and

general principles, noting that not all such prin-

ciples 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:

Editorial: Expert and expertise: meanings and perspectives 175



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• 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 princi-

ples 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 know-

ledge 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 inter-

pretative rather than prescriptive’.

Deliberative decision-making, as characterized by

Schon (1983), begins with practitioners imposing

an interpretative framework that defines the situ-

ation 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 satis-

factoriness 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 practi-

tioner 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 dis-

covering 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).




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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:

1

None of the four definitions is self-sufficient.

2

All four definitions make a significant contribution

to professional expertise.

3

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 dimen-

sion, 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 accom-

panied 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, suggest-

ing 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 discus-

sion 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. More-

over, 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




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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. More-

over, 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 manage-

ment 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 over-

arching 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. Progres-

sion beyond competent is then associated with the

gradual replacement of deliberation by more intui-

tive 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 concom-

itant increases in speed and productivity

• Increasingly,

intuitive decision-making

, in which

not only pattern recognition but also rapid responses

to developing situations are based on tacit knowledge

– the tacit application of tacit rules.

Both Dreyfus & Dreyfus (1986) and Benner (1984),

who used the model for interpreting her research into

the expertise of critical care nurses, cite evidence to

support the widespread use of rapid intuitive

decision making by experts, but do not establish

their claim that deliberation has become virtually

redundant. Benner recognizes two situations where

analytical approaches might be required: when

an expert is confronted with a situation of which she

has no previous experience; or when the expert gets

the wrong grasp of a situation then finds that events and

behaviours are not occurring as expected. Dreyfus

& Dreyfus (1986) suggest yet a third possibility,

that ‘detached deliberation about the validity of

decisions will improve decision-making’ (p. 164).

Roughly translated, their advice is that if an intui-

tively derived decision proposal does not feel right

or has an equally compelling alternative, think it

through and check it out. However, this limited use

of deliberation has one major problem: the need to

explain one’s thinking to colleagues and to clients.

This disagreement can be resolved by adopting

Bereiter & Scardamalia’s (1993) distinction among

‘experts’, ‘experienced non-experts’ and ‘routine

experts’. Their first distinction is that experts ‘solve

problems that increase their expertise and deepen

their understanding, whereas non-experts are likely

to tackle problems that do not make them grow and

develop themselves’. Experienced non-experts are

those who work in an environment that encourages

growth but continue to stick to familiar routines. I

would describe them as stuck at the Proficient level




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of the Dreyfus progression. Routine experts work in

an environment that offers little scope for growth

and whose ability and disposition to adapt are still

unknown. They are also working at the Proficient

level but might become experts if they changed

their workplace. In this departure from the Dreyfus

Model, the experts are characterized by what Bereiter

& Scardamalia (1993) call ‘progressive problem

solving’ and they try to construct a career that offers

them the appropriate opportunities. For experts,

career progress is likely to involve searching for work

contexts that provide such support. Hence, it is

useful to regard the development of professional

expertise as a career characteristic.

Finally, I return to the most frequent and penetrat-

ing criticism of the literature on experts and expertise,

its cognitive bias. Its main propensities are sum-

marized by Hakkarainen

et al

. (2004) as follows:

1

‘It pays too much attention to mental processes and

events rather than concrete activities taking place

within sociocultural contexts and situations’.

2

‘It focuses on mental representations rather than

various external representations, tools and knowl-

edge embedded in the environment that people are

using to manage their limited cognitive resources’.

3

‘It assumes that intellectual processes follow a short

timescale of almost instantaneous reasoning pro-

cesses (i.e. processes taking place within one session

of thinking) rather than extend across expanded

periods of time’. [This is supported by a substantial

body of research into Naturalistic Decision Making

(Klein

et al

. 1993).]

4

‘It assumes that intellectual activity takes place

at the level of the individual agent, and is primarily

dependent on his or her mental capacities, rather than

distributed across several agents and dependent on

characteristics of their social organization’ (pp. 7–8).

Hakkarainen

et al

. (2004) then go on to argue

that: ‘If expertise is examined only at the individual

level, explanation of the development of expertise

becomes very difficult and mysterious’ (pp. 8–9).

Hence, their recent research sought to combine

evidence on ‘individual and social aspects of expertise,

as well as more specific analysis of relations between

these levels’; by focusing on ‘networked expertise’,

which they define as ‘higher level cognitive compe-

tencies that arise in appropriate environments, from

sustained collaborative efforts to solve problems and

build knowledge together’ (ibid p. 9).

Two key principles that emerged from the research

of Hakkarainen

et al

. (2004) were the relational nature

of expertise and the co-ordination of individual

and social competencies. The relational nature of

expertise means that, in order to make a valuable

contribution to the community, an agent needs

‘to develop their knowledge and skills in relation to

their fellow actors in such a way as to allow them to

complement each other’s strengths and weaknesses’

(ibid p. 206). Hence, ‘moving to another community

produces special challenges because the agents need

to learn to adjust their activity to the knowledge and

skills of others and find a “slot” that allows them to

develop and utilize their own expertise’.

‘Initially, new members of a group may feel that

they do not “fit” into a team, and feel uncomfortable

and alienated; and it takes a great deal of cognitive

effort and reciprocal interaction to … find one’s place

within a social community and, thereby, create a

basis for developing one’s networked expertise’ (ibid

pp. 206–7). Thus, joining a new community has

emotional as well as epistemic aspects.

Michael

Eraut

Editor

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Expert and expertise: meanings and perspectives