What defines expertise in regional anaesthesia? An observational analysis of practice.

BACKGROUND Published work on knowledge in regional anaesthesia has focused on competence, for instance by identifying numbers of procedures required to achieve competence, or by defining criteria for successful performance of blocks. We aimed to define expertise in regional anaesthesia and examine how it is acquired. METHODS We observed anaesthetists performing 15 regional anaesthetic blocks and analysed the resulting transcripts qualitatively and in detail. RESULTS Expertise in regional anaesthesia encompasses technical fluency but also includes non-cognitive skills such as handling of the patient (communicating, anticipating and minimizing discomfort) and recognizing the limits of safe practice (particularly deciding when to stop trying to insert a block). Such elements may be underplayed by the experts who possess them. Focusing on a small number of regional anaesthetic procedures in detail (as is standard with such qualitative analytical approaches) has also allowed us to develop a model for the acquisition of expertise. In this model, trainees learn how to balance theoretical and practical knowledge by reflection on their clinical experiences, an iterative process which leads to the embedding of knowledge in the expert's personal repertoire of individual techniques. CONCLUSIONS Expertise in regional anaesthesia extends beyond competence at technical performance; non-cognitive elements are also vital. Further work is needed to test our learning model, and the hypothesis that learning can be enhanced by deliberate promotion of the tacit elements of 'expertise' we have described.

[1]  Characteristics of good anaesthesia teachers , 1997, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[2]  Jill Gordon,et al.  One to one teaching and feedback , 2003, BMJ : British Medical Journal.

[3]  John Spencer,et al.  Learning and teaching in the clinical environment , 2003, BMJ : British Medical Journal.

[4]  J. D. Greaves,et al.  Watching anaesthetists work: using the professional judgement of consultants to assess the developing clinical competence of trainees. , 2000, British journal of anaesthesia.

[5]  M. Sivarajan,et al.  Objective Evaluation of Clinical Performance and Correlation with Knowledge , 1984, Anesthesia and analgesia.

[6]  C. Pope,et al.  Passing on tacit knowledge in anaesthesia: a qualitative study , 2003, Medical education.

[7]  T. Crozier.  Clinical Teaching - A Guide to Teaching Practical Anaesthesia , 2003 .

[8]  W. Tweed,et al.  The experiential curriculum: an alternate model for anaesthesia education , 1994, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[9]  C. Dodds,et al.  Clinical Teaching: A Guide to Teaching Practical Anaesthesia , 2002 .

[10]  D. Kolb.  Experiential Learning: Experience as the Source of Learning and Development , 1983 .

[11]  D. Kopacz,et al.  The Regional Anesthesia “Learning Curve”: What Is the Minimum Number of Epidural and Spinal Blocks to Reach Consistency? , 1995, Regional Anesthesia & Pain Medicine.

[12]  D. Schoen.  The Reflective Practitioner , 1983 .

[13]  D. Schoen,et al.  The Reflective Practitioner: How Professionals Think in Action , 1985 .

[14]  A Smith,et al.  Expertise in practice: an ethnographic study exploring acquisition and use of knowledge in anaesthesia. , 2003, British journal of anaesthesia.

[15]  D. Kopacz,et al.  QA in regional anesthesia training: quantity or quality? , 1997, Regional anesthesia.

[16]  E. Mascha,et al.  A survey of exposure to regional anesthesia techniques in American anesthesia residency training programs. , 1999, Regional anesthesia and pain medicine.

[17]  A. Ronai,et al.  Influence of anesthesiology residents' noncognitive skills on the occurrence of critical incidents and the residents' overall clinical performances , 1991, Academic medicine : journal of the Association of American Medical Colleges.

[18]  Christoph Konrad,et al.  Learning Manual Skills in Anesthesiology: Is There a Recommended Number of Cases for Anesthetic Procedures? , 1998, Anesthesia and analgesia.

[19]  P. Atkinson.  Handbook of ethnography , 2001 .

[20]  D. Kennedy,et al.  Life-threatening Ventilatory Obstruction due to a Defective Tracheal Tube during Spinal Surgery in the Prone Position , 2005 .

[21]  D. Benhamou,et al.  Survey of Regional Anesthetic Practice Among French Residents at Time of Certification , 1997, Regional Anesthesia & Pain Medicine.

[22]  Donald A. Schön.  The reflective practitioner : how professionals think in action , 1986 .

[23]  Matthew B. Miles,et al.  Qualitative Data Analysis: An Expanded Sourcebook , 1994 .

[24]  Jeremy C Wyatt,et al.  Keeping up: learning in the workplace , 2005, BMJ : British Medical Journal.

[25]  Donald A. Sch.  The reflective practitioner: how professionals think in action , 1983 .

[26]  Jane Hendy,et al.  Challenges to implementing the national programme for information technology (NPfIT): a qualitative study , 2005, BMJ : British Medical Journal.

[27]  D. Silverman.  Interpreting Qualitative Data: Methods for Analysing Talk, Text and Interaction , 1994 .

[28]  J. Fraser.  Teaching practical procedures in general practice. A primer for supervisors of medical students and registrars. , 2003, Australian family physician.

[29]  R. Flin,et al.  The role of non-technical skills in anaesthesia: a review of current literature. , 2002, British journal of anaesthesia.

[30]  D. MacKenzie,et al.  Tacit Knowledge, Weapons Design, and the Uninvention of Nuclear Weapons , 1995, American Journal of Sociology.

[31]  Training requirements for peripheral nerve blocks , 2002, Anesthesiology.

[32]  J Savage,et al.  Ethnography and health care , 2000, BMJ : British Medical Journal.

[33]  J. M. Davies,et al.  Qualitative Research in Health Care , 1996, Journal of the Royal College of Physicians of London.

[34]  I. Kestin,et al.  A statistical approach to measuring the competence of anaesthetic trainees at practical procedures. , 1995, British journal of anaesthesia.

[35]  D. Kopacz,et al.  Regional Anesthesia and Pain Medicine: Residency Training—The Year 2000 , 2001, Regional Anesthesia & Pain Medicine.