The Many Faces of Expertise
The notion of expertise is pervasive in medicine. Students know who the expert physicians are: they migrate to them and follow them around. Medical educators design elaborate curricula specifically to convey it. Practicing physicians know which of their colleagues embody expertise: they request consultation from those colleagues (and not from others) on difficult cases. Courts and policy makers rely on the testimony of medical experts: their decisions would be questioned without it. Yet an exact definition of the medical expert has proved elusive, and the topic of expertise in medicine had received, until recently, relatively little explicit attention. This seems to be changing.
Medical diagnosis was one of the earliest areas to be explored [1-3]. What makes someone an expert in diagnosis? Is there a particular kind of reasoning or methodology underlying the diagnostic expert? Can diagnostic expertise be taught and, if so, how? Can it be acquired from computerized simulations? Can we expect diagnostic expertise of every clinician? Can we hold a clinician legally responsible for not possessing it? Getting a clearer handle on the notion of expertise in the area of medical diagnosis matters and has myriad implications for education, policy, economics, law, and ethics. Yet medical diagnosis is just the beginning. The notion of expertise is as prevalent in discussions of surgical skill, therapeutic intervention, court testimony, and bioethics consultation [4-7].
The February issue of Virtual Mentor explores the topic of medical expertise from some of its varied appearances in medicine today as a way to further the understanding of expertise in medicine. The authors represent a diverse group, all of them tied together by an interest in the topic of expertise in medicine. Drs Mark Tonelli, Henry Perkins, and Paul Rockey begin this issue with analyses of 3 clinical cases. Tonelli critiques the movement toward evidence-based medicine (EBM) and argues against an understanding of EBM that replaces traditional notions of clinical expertise. Perkins and Rockey look at expertise in clinical ethics consultation, the former from the perspective of cultural competence and the latter from the perspective of clinical expertise in its different components. The legal profession has had to decide what it will admit as expert medical testimony, and Allison Grady analyzes the classic case, Daubert v Merrell Dow Pharmaceuticals. Abraham Schwab and Lisa Rasmussen explore the role that expertise plays in the public face of bioethics, the former by proposing a possible credentialing of bioethicists and their expertise and the latter by taking a critical look at bioethics consultation for pharmaceutical companies. Louis Halamek gives us a glimpse into the possible future uses of simulation-based teaching in the acquisition of expertise in medical education. Erin Egan argues for the benefits of the hospitalist movement, while Jeremy Snyder and Brian Zanoni point out some of the potential pitfalls, engaging in a spirited debate over specialization in medicine. Karunesh Ganguly gives a concise overview of the challenge of diagnosing multiple sclerosis. Finally, I review a classic article by Edmund Pellegrino on the topic of clinical expertise.
My hope is that you will come away from this issue of Virtual Mentor with a better understanding of the importance that expertise plays in medicine and medical ethics. The discussions in this issue may not provide an exact definition of expertise but they seem to suggest the boundaries for one. Expertise involves mastering some area of knowledge and in turn using this mastery to educate others or skillfully practice one’s craft. Medicine is practiced on a presumption of expertise; a deeper understanding of it may promise a deeper understanding of medicine itself.
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