Remember Nurse Ratched in One Flew over the Cookoo’s Nest? Louise Fletcher won the Oscar for a brilliant portrayal of the emotionally and empathetically unconnected expert who always knows best.

Last weekend I had the privilege of acting as native guide to Gary Klein and his wife Helen, starting with a walk in the Brecon Beacons and a day in Hay-on-Wye. My daughter was with us and given her Masters thesis was on the nature of expertise and the role of the expert patient the conversations walking over the hills was stimulating. Gary’s work on the nature of expert judgement is seminal and I’ve drawn heavily on it over the years. We will be teaching together in Singapore shortly as well so this was a time to consolidate methods and recognise differences; more important for learning than commonalities. Both of us recognise the limitations of expertise, understand the nature of bias but also very explicitly deny the derogation of expertise. The issue for me remains one of context. In Cynefin terms

  1. In the Obvious domain you simply should do what you are told by an expert
  2. In the Complicated domain in the main experts will be right far more than they are wrong, but at an individual level you may be an outlier so there may be issues
  3. In the Complex domain then outliers and variations from the norm start to dominate and you need to have several perspectives and hopefully maintain an approach which keeps options open for as long as possible
  4. In the Chaotic domain experience matters more than expertise, but expertise still counts.

Now there is more to come here, but for the moment I’d just point out that there are well established approaches to deal with this. If you look at the medical profession we have nurses who start with experience and acquire theoretical knowledge and doctors who start with theory and then acquire practice. There are also established norms and rituals for their various interactions. You see the same in the Armed forces with the distinction between NCOs and Officers. Other professions such as lawyers and accountants have had, and to a degree still do have such models. This is a body of knowledge and we should not allow the term to be corrupted into an information system as it has been in project management and the absurdities of knowledge management accreditation schemes. In those cases an approach has evolved over time with some elements of design and management. It has not been engineered bottom up.

We will be announcing projects shortly to create a SenseMaker® approach to patient journey based on the huge success of Christine and her team with 10,000 Voices in Northern Ireland. Part of that is to create a different way of interacting between patients, carers and professionals that is not depending on spacial or temporary proximity to trusted advisors. More on that in the next few weeks I hope, all part of the Meaning project.

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