Home Volume: 1, Issue: 1
International Journal of Healthcare Simulation
Adi Health+Wellness
People being expert
DOI:10.54531/XMVM2706, Volume: 1, Issue: 1, Pages: 61-62
Article Type: Perspective, Article History

Roger Kneebone is a people person, and his calm, contemplative charm must have made a significant contribution to the rich texture of this book: his distillation of what experts share as humans ‘having expertise is one thing. Being expert is another … this book is about real people’. I am confident the experts usually enjoyed being observed, studied, facilitating the depth of this investigation. I first enjoyed this book – Expert: Understanding the Path to Mastery (1), from a sun-lounger between a blue Mediterranean sea and a blue Turkish sky, it is eminently readable.

Kneebone’s personal journey into experts and expertise expands over time, beginning as a surgeon intimately occupied with the momentary welfare of one patient (one organ, one element of tissue) and one team. Later a GP considering families and communities over time, and with several teams … this becoming a cascade: a musician; an educator and researcher planning for entire classes, cohorts of students, and students of his students. Now, with this book, so much more so than even his wide-ranging and celebrated work on public engagement, he addresses the world. But a book, you know, is essentially a one-way street from author to reader, and still, being expert seems a lonely travail.

The book describes the path to mastery via the stages of apprentice, journeyman and master; the experiences of ‘doing time’ (no better phrase for the drudgery of being the nominated doer of endless, superficially menial, tasks), ‘using your senses’, being sensitive to ‘space and other people’, understanding ‘it’s not about you’ and ‘developing voice’ until the master yearns to be an expert in ‘passing it on’. We are familiar with simulation as a tool to support the journey to expertise, but this book illuminates how much more we can do to investigate what being expert means, and the environment in which that can flourish. Pithy nuggets are given on almost every page. For example, discussing ‘It’s not about you’, reflecting on that as distinct from ‘developing voice’ and ‘passing it on’ which resonate with public engagement. There is a world of opportunity we must continue to explore using simulation to keep the voice of a human at the heart of learning about care (perhaps in a new insight with ‘doing time’): the thinking eloquently conveyed here gives one cause to reflect on the experience of expertise from every viewpoint.

Skilfully woven: Kneebone uses narrative and anecdote, with moderation. A meditation, modestly but honestly prepared to celebrate what Kneebone describes as being expert: still not feeling like an expert, whilst acknowledging ‘it probably looks that way from the outside’. This theme continues: the book ends neatly with a meditation on the perpetuity of becoming, and of unfinished work. There is so much here to inform the role of simulation in becoming expert about people who care. Kneebone asks us to consider that ‘the perceived value of an expert’s work has a lot to do with how we judge it, and this can be misleading … the essence of being an expert … cuts across these unhelpful hierarchies’. ‘The point about being an expert is not the field you are in but what you have to do to get there.’ These share unvoiced instruction, from unhelpful monosyllables to a touch of a hand. Experts rarely explain – verbalize – what they do but may be able to demonstrate it, we can do more to optimize this, and it will require simulation both in research and then informing better simulation.

Expert work invariably is work done for somebody else, the wearer, the observers, the patient, the passengers. Being an expert seems essentially lonely work, filled with vital yet transient engagements with others; ‘there are changes in who you are, not just what you do … a perpetual state of becoming’. This is a place for simulation to empower sharing – so many experts will never share expertise with an expert in the same field – or another, but we can bring them together in simulation, maybe going somewhere fresh, break rules (and Kneebone describes this (2), but I am convinced the freedoms of simulation have still more to offer) informed by the shared experiences of being expert this book brings to us.

Which lessons cannot be taught?

Given his outstanding and prolonged activity as an innovator and expert in the field, it is probably disingenuous to wonder whether discomfort as to the role of simulation in making ‘doing time’ efficient and an agreeable contempt for the common preference for instant success may have influenced interest in simulation with objectives other than learning. ‘Becoming …doing time’, the earnest learner marinades, being tenderized into acceptance and becoming the role by osmosis that requires a long soak. This conflicts with simulation as a tool for efficient training – speeding things up – and perhaps hence the progression from procedural skill to ‘transformative simulation’ in which an outcome other than learning is the primary goal. How much of ‘doing time’ is about demonstrating an investment in the system for the common good? That it is frustrating and unnecessary, but it is an essential component of making a commitment, earning one’s place, readied to steel oneself to inflict pain in the cause of learning as well as healing, ‘coming to terms with causing discomfort’ – surely avoiding or at least optimizing this is a simulation gift? We understand that ‘first do no harm’ (‘primum non nocere’) is inappropriate, and much care is a cost/benefit of non-maleficence/beneficence: ‘do no net harm’. What if both practitioner and the trusting patient knew that training science was such that the exact ideal number of errors and amount of pain necessary to ensure a perfect journey of ‘doing time’ would proceed? That one more moment at the task-trainer was proven to be a futile waste of that resource, on the wrong side of the cost/benefit balance?

‘To this day I cannot understand why nobody said anything’

Whilst the issue of error is addressed, with a steely clinical gaze, it is approached primarily in terms of the lonely self-management that evolves in the being of an expert – formed from predictive coding and the awareness that empowers not being surprised. Whilst error is addressed far beyond the minor slips and lapses that denote ‘challenging times’ and having our ‘ups and downs’ there is necessarily less focus on consequence. Of course, the consequences of error can be self-inflicted, inflicted upon others, or shared. Demonstrating the breadth of experience brought to bear in this book the author can bring us an experience of error as a pilot, a luckily harmless near-miss which serves to induct him into the community of practice of experts who own error.

There is eloquent discussion of ‘getting it wrong and putting it right’ and the failure to speak up, but there are depths unplumbed here. Error and resilience, improvisation and more are addressed, but I would argue the book shies away from the darkest personal horrors of error, what is described tends to be observed, reversible, low consequence, near miss, rather than irrevocable personal mistakes and the oubliette of responsibility from which the expert must climb. Does breaking a pot feel like breaking a heart, can we get the brain MRI of a tailor watching a surgeon make an error in simulation? There is gold here, simulation may be the best way to mine it.

So, for me this excellent book does much more than the required ‘passing it on’. One could argue that just as this book eloquently describes rather than offers advances; this review asks for more, deeper, rather than new frontiers. I am convinced that, just as this book illuminates the perpetual state of becoming an expert, there is much – perhaps an iconoclastic, pivotal moment – to learn about both experts in teams and experts in error. We all share frustrations about slow progress in patient safety, I suspect that important new clues about why, and a role for simulation, reside hiding in plain sight in this book.

Note: Professor Kneebone has a regular podcast: https://podcasts.apple.com/gb/podcast/countercurrent-conversations-professor-roger-kneebone/id1121211583. He has also many publicly available lectures that address content related to the book: https://www.youtube.com/watch?v=UiatG1Q-Oss



Kneebone R. Expert understanding the path to mastery. Penguin UK. 2020. ISBN: 9780241986141. The book is available from https://www.penguin.com.au/books/expert-9780241392041


Kneebone R . Perspective: simulation and transformational change: the paradox of expertise. Academic Medicine. 2009 Jul;84(7): 954957. doi: 10.1097/ACM.0b013e3181a843d6
This article is distributed under the terms of the Creative Commons Attribution-Share Alike 4.0 International License (https://creativecommons.org/licenses/by-sa/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated).