In this study, the perspectives of nine clinical trainees from a German university hospital on expertise in anaesthesiology were contrasted with the viewpoints of nine expert anaesthetists. At the time of the interview trainees described their first months of residency training as a very positive experience. The level of supervision and systematic mentoring received from more senior residents and from the attending physicians enabled novices to perform a broad range of unfamiliar activities in a safe learning environment. We do not take this feedback as granted as previous studies have reported a lack of adequate supervision in many medical specialties during the first months of residency [24, 25]. The discrepancy between what novices experienced and what experts were able to remember from their first months as novices may not only be the result of mere forgetfulness by experts but rather of the preponderance of using readily available knowledge about current performance over their own former learning experience . As people become more expert, they automate manual or simple tasks and develop a view of the task at hand in which the details of the task become less salient. As a result, expert supervisors may have difficulty understanding the particular kinds of challenges faced by novices when trying to familiarise with a new clinical environment and to learn novel tasks, even when reminded of these challenges. The interviews were intended in part to answer the research question of what novices think ‘expertise’ might entail and how this could inform the expert’s approach to clinical teaching. We can conclude from the novices’ responses that they actually do not deal with the same problems as researchers when it comes to understanding expertise. Novices struggle with very basic issues like translating theoretical knowledge into meaningful and appropriate action and acquiring vital skills. They do not spend much time thinking about expertise: it is simply not yet on the horizon. Their almost complete lack of concern in developing expertise is also reflected in the novices’ responses about what they can contribute to becoming an expert. The main issues they raised were the acquisition of theoretical and practical knowledge and the need for a supportive environment. Experts, by contrast, stated that seeking challenges and continuously stretching performance boundaries had been vital for becoming an expert. In a similar vein, the notion of leaving one’s comfort zone and of practicing deliberately have been identified as a hallmark of excellence [27, 28]. We interpret the relative absence of the idea of leaving one’s comfort zone from the novices’ responses as an indication that novices can only start leaving their comfort zone once they have found one, and this requires a solid basis of clinical experience.
A common understanding shared by every novice and expert was that the development of expertise was a socially embedded process facilitated by an organisation where peer discussions were possible without fear of being ridiculed and where mentors and peers were willing to share their knowledge. The social nature of expertise reappeared in the understanding of experts that expertise in anaesthesia emerged from teamwork endeavors, often on an interdisciplinary level with a range of clinical partners. Both groups agreed that every expertise will eventually reach its limits and that it might be a challenge for the expert to accept this and ask for help. In contrast to studies on help-seeking behavior in surgeons , where calling for help is seen as a threat to the expert’s image, autonomy, and development as independent practitioner was not mentioned by our experts. A characteristic feature of all the responses was the assessment that expertise was neither a monolithic feature, readily recognizable by everyone nor a quality that, once acquired, would necessarily endure over an entire professional life. Similar to other interviewees  our respondents believed that expertise depends to some extent on s social context and is in an important sense, never fully general .
While expert supervisors had difficulty understanding the particular kinds of challenges faced by novices during their first months, novices were unable to comprehend the dilemmas experts face when forced to reconcile strict guidance by evidence-based rules and personal experience in the treatment of an individual patient. Novices saw rules as the embodiment of the best possible way of carrying out activities, covering all known contingencies. They assumed that following written procedures would guarantee patient and staff safety. Expert anaesthetists, by contrast, took the view that rules and standards were essentially underspecified, requiring experience and expertise to translate them to any specific situation . This is because the variability of diseases and patients and the interactions across patient conditions spill over the category boundaries of best-practice guidance. In addition, the scientific evidence presented in written guidelines and recommendations does not always speak for itself but needs to be interpreted, revised, and tailored to specific contexts and conditions, all of which takes experience and expertise [30, 32,33,34]. As a result, experts believed that in some situations patient safety could only be guaranteed by not following rules if this was supported by a valid mental model or social understanding or both of the situation . Interestingly, these two perspectives mirror the two contrasting ways of thinking about the functions, strengths and limitations of rules and standards safety science knows of .
While experts commented on the challenges they encountered when trying to negotiate evidence-based medicine (EBM) standards and personal experience, trainees stated that that evidence-based standards often played a subordinate role to the ‘quasi-normative rules’  consultants had established. To our knowledge, this aspect of expertise development has not yet been mentioned in the anaesthesia education literature. For experts, experience may occasionally trump EBM-based rules. For novices, it appears, quasi-normative rules always trump things like EBM-based rules.
A central premise of theoretical and empirical research about expertise is that it is the level of tacit knowledge acquired that distinguishes experts from novices. Given the fact that the novices had only recently finished medical school and had on average 4 months of clinical experience at the time of the interview, it does not come as a surprise that their responses did not reveal any understanding of tacit knowledge or intuitive decision making in anaesthesia. Instead, novices conceptualized decision making as a very rational, conscious, and deliberate step-by-step process. This observation may reflect the fact that a person often cannot imagine, let alone conceptualize an experience he or she has not yet had. Instead, similarity matching and representativeness favor current and familiar experiences as the basis for understanding  which in the case of recently graduated medical students most probably will be hypothetico-deductive reasoning taught and prioritized in higher education. Experts, in contrast, knew exactly what intuitive decision making feels like and were able, at least to some extent, to talk about it. In addition, they reported that they checked their intuitions with conscious deliberation before acting upon the first, an approach that has been termed ‘informed intuitions’ in the literature on decision making .
What this study adds to our understanding
The current research adds three aspects to the medical education literature on education for expertise development: First, it describes the perspective of novices in their first months of clinical rotation on the development of expertise. To our knowledge, no previous qualitative research has explored junior residents’ perspective on this topic at this point in their careers. Although the data of this study was gathered in anaesthesiology there is reason to believe that novices in other specialties face similar challenges when trying to familiarise themselves with routine clinical work. Taking into account the viewpoint of novices can help expert clinical teachers to identify concepts shared by both groups and to focus their teaching on aspects of professional development novices are currently unaware of.
Second, the responses given by the experts illustrate the fact that neither clinical experience alone nor strictly following evidence-based measures are a sufficient prerequisite to create expertise. Rather, the successful negotiation of evidence derived from clinical research with experience and pathophysiological knowledge in the treatment for an individual patient is a pivotal moment in the development of expertise .
Finally, the novices’ comments on the challenge of how to familiarize themselves (and reconcile) the ‘quasi-normative rules’  of different attendings draws attention to a hidden curriculum of residency training that could inhibit the development of mature clinical decision making. These quasi-normative rules may be an unwanted result of the traditional apprenticeship model of residency training in which trainees are expected to imitate the role model of the supervisor . In a more resident-directed model experts should render the processes involved in their problem solving of complex cognitive tasks more explicit, hereby teaching the trainee how to articulate the reasoning behind a decision . Rather than taking a normative stance towards the one right treatment path, expert supervisors should address the complexities, nuances, and ambiguities of clinical situations to enhance decision making skills among novices . To strike the right balance between acceptance of ambiguity and plurality of clinical work on the one hand, and clear guidance of unexperienced novices on the other, is certainly not an easy task for clinical educators. Nevertheless, whenever expert supervisors expect residents to strictly follow ‘quasi-normative rules’ despite the danger that such rules can oversimplify  they may actually delay the development of critical clinical thinking, an ability that residency training programs in any specialty should be designed to encourage .
The limitations to this study are identical to those of any qualitative interview study based on a small number of participants [40,41,42]. The interview was performed at one location and data has been collected from employees at the Department of Anesthesiology at one German University hospital. Therefore, the responses of the participants reflect the organizational culture and structure of one hospital. It follows that the generalizability and transferability of the study results to other contexts will be limited. The convenience sample size of 9 novices and 9 attendings may not have allowed for data saturation and increasing the number of interviews might have strengthened the results of the study.
Further, the investigator was a colleague and in the case of the novices a direct supervisor which may have affected the responses in a negative or positive way. That is junior participants may have felt compelled to respond in a more socially acceptable fashion rather than feel free to provide a true reflection of their opinions. On the other hand, as the interviewer has worked with many of the experts, it is possible that this may affected the openness of the verbal exchange. Finally, the data was analysed and coded by only one investigator (M.St.P) which might have introduced a systematic bias into the research.