Novice to Expert

The novice-to-expert yellow brick road has been examined form many perspectives, including the nursing perspective.  Having been pretty hard on nurses in “There is a Nursing Shortage—NOT,” I feel compelled to give the profession credit for its awareness that novice nurses are not as proficient as expert nurses, and the profession’s attempt to get a handle on why this is so.

In 1984, Patricia Benner, applied the novice-to-expert research of Hubert and Stuart Dreyfus to nursing studies in her book, From Novice to Expert: Excellence and Power in Clinical Nursing Practice. A commemorative edition of the book is now available. Even a cursory search online will turn up many articles about Benner’s work, including summaries of the hierarchy of skills in the transformation of a novice into an expert.

The term intuition has so many subjective meanings to so many people that the discussions of expertise becomes bogged down in whether intuition is really part of expertise.  After all, intuition is what it is because it is thinking outside the box, outside the rules. And this is offensive to many people trying to define expertise, especially expertise in the medical professions where electronic medical records require checkboxes and the Center for Medicare Services is becoming absolutely obsessive about linking those check boxes with it’s new MACRA rules.

In a 1991 article, Bent Flyvbjerg interviewed Hubert and Stuart Dreyfus and discussed how their theories had developed since the 80s. Hubert and Stuart Dreyfus began using the term intuition for that top level of expertise when the solutions to the problems faced by an expert are instantly “known” without any obvious time to consider rules, the circumstances, or any of the things the logical mind expects in a decision-making process.Shadowing much of this interview is our western philosophical compulsion to label things right or wrong, black or white, or rational and irrational, or in terms popular in the medical professions, rule-based or evidence-based, as opposed to something which “doesn’t follow the rules.” Critics of the Dreyfus brothers become fixated on this notion of rules versus intuition, as if the Dreyfus brothers were actually suggesting that the transition from novice to expert meant one or the other, adherence to rules or non-adherence to rules.

Hubert and Stuart Dreyfus understand that “Intuition does not reside in the body or the mind. It resides in the fact that the brain can store whole gestalts (Flyvbjerg, p. 68). “

There has been much neurological research indicating that our minds work holographically to store the gestalts spoken of by Hubert Dreyfus, most notably, Karl Pribram. Frankly, I’m puzzled why there isn’t more reference in these educational discussions of the novice-to-expert continuum to the longstanding research in holographic thinking. Many years ago, Danial Goleman interviewed Karl Pribram about his findings, and a more detailed analysis of Pribram’s continuing work in this area can be found on the Scholarpedia site.

Ah…yes, to the point.

The medical field is becoming more and more rule-based even though anyone with any reasonable understanding of medicine “knows” that the practice of medicine requires higher level thinking skills than following tidy rules alone. Rules alone simply generate cookbook medicine.  Our horrendous compulsion to try to control the uncontrollable by labeling something right or wrong—even if it doesn’t work— goes right on marching.  Government regulations continue to generate rules which demand novice adherence at the expense of expert intuition, strangling the ability of physicians to provide the very quality medical care the “rules” are supposed to guarantee.

Hubert and Stuart Dreyfus know that you can’t legislate quality or value (Flyvbjerg, p. 100-101).  Their years of research tells them so.  Karl Pribram’s research supports this notion as well.  Yet health care regulators have now advanced beyond the point of making rules to regulate the care of medical providers, but are now advancing the totally irrational notion that they can formulate rules which will measure “quality.” Rules by definition keep the practice of medicine at the novice level—if the rules make no allowance for expertise.

We are already well on the yellow brick road to lousy medical care for all with rules, regulations, and penalties to physicians who step outside the box—the known marker of expertise. No rule-making grid enforced by penalties to physicians is going to correct what cannot be corrected with rules. It’s time for regulators and payers to return to physicians their ability to treat and diagnose their patients based not only upon rules, but also upon their expertise, as in the treating physician.

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