Comparative analysis of the understanding of 'expertise' and 'resilience' in novice and expert anesthesiologists

Sammanfattning: Anesthesiology is the medical specialty dedicated to the relief of pain and care of the surgical patient before, during and after surgery. Most of the work in anesthesiology is routine patient care, but because patients are sick and surgical procedures may develop in unexpected ways, anesthesiology by its nature often involves medical crises. In recent years, two concepts have gained increasing importance in literature on safe patient care in anesthesiology: the expertise of the caregiver in routine and crisis situations as well as resilience and the ability of the caregiver to ‘behave resiliently’. All studies identified in the literature review, in which anesthesiologists were interviewed on expertise or resilience, used an inhomogeneous set of novices and experts as study group. No study has yet looked at how novice anesthesiologists who for example just graduated from medical school conceptualize expertise and resilience. In this qualitative, exploratory study, a group of nine novices from the Department of Anesthesiology of the University Hospital Erlangen, Germany, with a mean clinical experience of 4.3 months were interviewed about their understanding of ‘expertise in anesthesiology’ and ‘resilience in anesthesiology’. Their responses were contrasted with the perspectives of nine expert anesthesiologists from the same department, averaging 26.7 mean years of professional activity in anesthesiology. Novices found it difficult to talk about or define expertise as they still struggled with translating theoretical knowledge into action and with acquiring vital skills. The complexity of routine tasks in new environments was the major challenge for novices, a challenge that experts no longer remembered much about from their residency training. A common understanding shared by novices and experts was that the development of expertise is not an individualistic endeavor but rather a socially embedded process. Novices appeared to think that following written procedures would guarantee safety because they were specific enough to addresses every clinical contingency. Experts took the view that rules and standards were essentially underspecified, requiring experience and expertise to translate, adapt and enact them. While experts were able to describe how they negotiated standards and recommendations with clinical experience, novices stated that evidence-based or institutional standards seemed to play a subordinate role to the quasi-normative rules of attendings. Novices conceptualized decision making as a very rational, conscious, and deliberate step-by-step process and did not reveal any understanding of tacit knowledge or intuitive decision making. Experts, in contrast, described intuitive decision making and used terms like “intuition”, “gut feeling”, and “7th sense”. The increasing interest of safety scientists to understand safety by applying the concept of resilience is hampered by the fact that the term is often used in multiple, diverse and, sometimes, incompatible ways. Anesthesiology is no exception to this rule and as it appears that the notion of ‘resilient behavior in anesthesiology’ is actually a relabeling of non-technical skills. In addition, the way ‘resilience’ is used in anesthesiology focuses on individual behavior and often ignores the fact that resilience is a system property that emerges from the interactions at the micro/meso/and macro level. It is questionable whether this re-labeling of non-technical skills to ‘resilient behavior’ will improve the practice of anesthesia or create any new insights.