Saturday, 1 June 2013

Does it matter how we acquire knowledge and expertise?

Knowledge and expertise are two very topical words in healthcare at the moment, but I want to challenge how we perceive and value them.

In the Collins English Dictionary that sits on my shelf, knowledge is defined as the 'facts or experiences known by a person or group of people', whilst expertise is defined as 'special skills, knowledge or judgement'. It surprised me to read that knowledge could include facts and experiences - the traditional paternalistic medical world seems to define knowledge as facts and dismiss experience. If knowledge can really truly encompass experiences, then my favourite term, experts by experience, is very much valid!

This wider definition of knowledge is slowly becoming accepted in the medical communities. I feel that we are moving away from the culture of "Doctor knows best". The knowing and knowledge to which that refers is very narrow (national clinical guidelines, drugs and tests, and the pathology of disease) but medicine is an art and science and a broad one at that. Accepting that knowledge covers both the facts, known best by the clinicians, and the experience, lived by the patient, we can turn the doctor-patient relationship into an equal one, and the perfect environment for shared-decision making.
So now we are in this situation, and although for many of us, we can see the benefits, some remain resistant to the idea that knowledge can be shared with patients. It was summed up perfectly in a tweet during #SDMchat in March:

I think there is an inherent preference for knowledge based on facts over experience. Aside from the scientific focus of many clinicians and people within the healthcare service, and the rise of 'evidence-based medicine', I am beginning to realise that our wider culture favours and rewards fact-based knowledge over knowledge acquired through experience. 

Let's take two contrasting examples of the way people gain experience and how that experience is valued.
My clinicians gain experience through a rigorous academic process that is regulated and recognised. Rightly so.
My experience has been gained through a mishmash of relapses, drugs, appointments and the long months in between. While we respect the expertise of doctors acquired through such clear pathways, the value of patients experience is always going to be questioned, as it does not fit this recognised model of institutions and qualifications.

My new alma mater?
Holding a degree from my first three years of medical school, I never thought anything would be more important. Those letters after my name were a clear sign for all to see that I had (factual) knowledge. I now value my (experiential) knowledge as a patient higher, and feel I have learnt more since than I ever did in those three years crammed full of study. But from the outside, those first three years and that qualification are still deemed as knowledge and developing expertise, while what I have accumulated since is not seen as such. I feel like I am on track to get a first from the University of Life, but people are only seeing my mediocre degree from the University of Ivory Towers.

We talk about the patient experience and we want to hear the patient experience, but by limiting ourselves to just the experience, we are loosing the expertise that the experience generates. Experience is "knowledge or practical wisdom gained from from what one has encountered, observed or undergone". In a world where the Secretary of State announces that all managerial staff are to have front line experience, are we not ignoring the collective practical wisdom of a key group here?
Wisdom and expertise are not things can be gleamed from feedback forms - feedback has its merits, but is intrinsically too late.
We often talk about "learning from experience", and certainly for clinicians, learning by experience is a key part of their development, through time on the wards. Of all the experiences that patients undergo, there is a lot of learning happening too. . . But what happens with that learning? It doesn't count for credits for degrees, or other recognised building blocks of expertise, yet is invaluable if we want to continue to improve our healthcare services.

Expertise and knowledge are vitally important, whether they come from academic institutions and professional bodies or through life itself. Both are equally valid and essential, and should be respected as such if we want shared decision making to really work at the individual and collective level. We need to value the knowledge and expertise of all the people involved in these decisions - however that expertise has been acquired.

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