Evidence-Based Practice: Evaluating the Term 'Clinical Expertise'
Back in the mid-90’s, Dr. David Sackett introduced a model for evidence-based practice (EBP) which was defined as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”
His model was built upon the integration of three variables:
- Best Research Evidence
- Clinical Expertise
- Patient Values and Preferences
While these 3 variables were identified as being key ingredients to EBP, I am disconcerted by the amount of weight many have given to #2 when discussing their own models of clinical practice. When Sackett defined this model, what did he really mean when he said “Clinical Expertise”? I went to some of Dr. Sackett’s original work to attempt to understand. And to do so, had to differentiate experience from expertise...
From a 1992 paper on this topic, Dr. Sackett stated:
” Clinical experience and the development of clinical instincts (particularly with respect to diagnosis) are a crucial and necessary part of becoming a competent physician. Many aspects of clinical practice cannot, or will not, ever be adequately tested. Clinical experience and its lessons are particularly important in these situations. At the same time, systematic attempts to record observations in a reproducible and unbiased fashion markedly increase the confidence one can have in knowledge about patient prognosis, the value of diagnostic tests, and the efficacy of treatment.
In the absence of systematic observation one must be cautious in the interpretation of information derived from clinical experience and intuition, for it may at times be misleading.”
In another paper, he described clinical expertise as:
“By individual clinical expertise, we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care.”
While attempting to disseminate Dr. Sackett’s thoughts on this subject, I began to suspect we need to clarify expertise. While clinical experience is important in improving professional confidence, it is not the same as expertise. I actually suspect experience alone can be associated with professional cognitive dissonance; especially when an experienced provider is challenged with evidence which is contradictory to their current practice.
Below I have proposed a provisional model of EBP, utilizing Sackett’s work in combination with an improved, measurable definition of clinical expertise.
My Proposed Model of EBP:
- Best Research Evidence
- Patient Values and Preferences
- Clinical Expertise as defined as: a. Practice built upon clinical reasoning development through measures of introspection, cognition and metacognition (this may be through formal post-graduate residency, fellowship or other formal mentoring opportunities. This will allow for peer-review of your ability to truly reason through clinical work). b. Practice built upon a model of critical thinking that is scientifically defensible and plausible
I propose clinical expertise is not simply gained through experience. It is built through an ongoing assessment of your ability to think, reason and apply scientifically plausible principles into practice. It requires peer-review. It requires your thoughts and ideas to be challenged. It requires a hint of uncertainty.
What do you think?
Gross experience does not mean that it was productive or challenged experience. If you want the same thing, then do the same thing. If you want something different, or expect something different, then you must do something different. Experience is great, but there must be challenges in order to grow. Steel sharpens steel. Clinical expertise comes with experience, yes, but has to be nutured and grown with sufficient challenges encountered during that time of experience. Good post Joe.
I agree with differentiating expertise versus experience, along with the emphasis on continually articulating thought process and clinical judgment, instead of exclusively resting on the laurels of experience and subsequently, making lazy assumptions with no intention of challenging what we know - how can we ever grow and advance if we don't question convention?
Well written Joseph. From my own experience, the greatest improvements in clinical reasoning occurred when challenged by post graduate education. It is easy to fool yourself and even your clients, but a lot harder to fool your peers. Exposing yourself, as uncomfortable and challenging as it is, to intense education is the key to improvement.