Abstract

Background. Published work on knowledge in regional anaesthesia has focused on competence, for instance by identifying numbers of procedures required to achieve competence, or by defining criteria for successful performance of blocks. We aimed to define expertise in regional anaesthesia and examine how it is acquired.

Methods. We observed anaesthetists performing 15 regional anaesthetic blocks and analysed the resulting transcripts qualitatively and in detail.

Results. Expertise in regional anaesthesia encompasses technical fluency but also includes non-cognitive skills such as handling of the patient (communicating, anticipating and minimizing discomfort) and recognizing the limits of safe practice (particularly deciding when to stop trying to insert a block). Such elements may be underplayed by the experts who possess them. Focusing on a small number of regional anaesthetic procedures in detail (as is standard with such qualitative analytical approaches) has also allowed us to develop a model for the acquisition of expertise. In this model, trainees learn how to balance theoretical and practical knowledge by reflection on their clinical experiences, an iterative process which leads to the embedding of knowledge in the expert's personal repertoire of individual techniques.

Conclusions. Expertise in regional anaesthesia extends beyond competence at technical performance; non-cognitive elements are also vital. Further work is needed to test our learning model, and the hypothesis that learning can be enhanced by deliberate promotion of the tacit elements of ‘expertise’ we have described.

The anaesthetist's education must encompass cognitive, psychomotor and affective elements.1 Current training syllabuses are set in terms of measurable competencies and quantifiable attributes. Concerns have been expressed for some time that trainees in anaesthesia receive insufficient experience in regional anaesthetic techniques.2,3 Attempts have been made to identify the minimum number of procedures necessary to achieve competence4–6 and improve the validity and reliability of assessment with the use of objective outcomes.7 There are many textbooks of regional anaesthesia and guidance on how to teach8 but we are not aware of any study describing how regional anaesthesia training is actually carried out in practice. Further, moves towards competency-based training have raised concerns that a rounded education in the total professional task of the expert anaesthetist may be lost.9 Our aims in this study were to define such expertise in regional anaesthesia and to examine how it is acquired.

Methods

The approval of the local Research Ethics Committee was granted for the study from which these data are drawn,10 and written informed consent obtained from patients being cared for by the anaesthetists under observation. We adopted a qualitative approach, grounded in detailed observation of regional anaesthetic techniques.11 Such research approaches are often used for the in-depth study of complex phenomena within the social context in which they occur and, as in this study, typically combine a range of methods.12,13 Operating sessions were purposively sampled to cover a range of different types of surgery and anaesthetic practice and levels of anaesthetic expertise. Observation was conducted principally by the same person (D.G.), but some sessions were conducted in tandem with one of the other researchers (C.P. or M.M.) to allow comparisons and internal validity checks on the data collection. Detailed contemporaneous notes were taken and transcribed immediately after the session. We also have some data on regional anaesthesia from the interviews conducted with anaesthetists and anaesthetic staff as part of the larger study.10

Analysis

The analysis began with individual close readings and annotations of the observational and interview transcripts. Collectively, through discussions and comparison of the various readings of the data, the dimensions and boundaries of the emerging themes and categories were refined.14 This inductive approach is typical of such qualitative work. Here, rather than using the data to test a pre-defined hypothesis, the results are suggested by the data themselves.

Results

We observed 15 attempted regional anaesthetics, of which 12 were successful (Table 1) and one tutorial on the subject of peripheral nerve blocks. Anaesthetists are denoted in interview and observation transcripts by A1, A2 etc. ODP denotes ‘operating department practitioner’.

Table 1

Regional anaesthetics observed (n=15)

Block Grade of operator Grade of supervisor Successfully inserted? 
Spinal 1 Senior house officer None No 
Spinal 2 Senior house officer Senior house officer No 
Spinal 3 Specialist registrar None No 
Spinal 4 Consultant None Yes 
Lumbar epidural 1 Specialist registrar Consultant Yes 
Lumbar epidural 2 Consultant None Yes 
Lumbar paravertebral 1 Senior house officer Consultant Yes 
Lumbar paravertebral 2 Consultant None Yes 
Femoral 1 Senior house officer None Yes 
Femoral 2 Consultant None Yes 
Ilioinguinal Consultant None Yes 
Penile Senior house officer Consultant Yes 
Ankle Senior house officer None Yes 
Interscalene brachial plexus Specialist registrar None Yes 
Cervical plexus Specialist registrar Consultant Yes 
Block Grade of operator Grade of supervisor Successfully inserted? 
Spinal 1 Senior house officer None No 
Spinal 2 Senior house officer Senior house officer No 
Spinal 3 Specialist registrar None No 
Spinal 4 Consultant None Yes 
Lumbar epidural 1 Specialist registrar Consultant Yes 
Lumbar epidural 2 Consultant None Yes 
Lumbar paravertebral 1 Senior house officer Consultant Yes 
Lumbar paravertebral 2 Consultant None Yes 
Femoral 1 Senior house officer None Yes 
Femoral 2 Consultant None Yes 
Ilioinguinal Consultant None Yes 
Penile Senior house officer Consultant Yes 
Ankle Senior house officer None Yes 
Interscalene brachial plexus Specialist registrar None Yes 
Cervical plexus Specialist registrar Consultant Yes 

Markers of expertise: flexibility and confidence

The slick practice of the expert performing a straightforward block meant that such cases were less illuminating than those where experts encountered difficulties, were called in to help others, or when trainees were working alone. Thus, for instance, we observed a consultant anaesthetist's first attempt to insert a femoral block in an awake patient, only to postpone the attempt as soon as it became apparent that it would hurt the patient. He subsequently successfully performed the block despite the abnormal anatomy of the femoral nerve in that patient, and in fact succeeded when he moved to the opposite side of the patient from where he would usually stand to perform the block. Expertise was also readily recognizable when it was absent, as in the extract in Figure 1 where two trainees, one (A1) 6 months more experienced than the other (A2), are working together. The patient had a fractured neck of femur and had been undergoing insertion of dynamic hip screw. Our impression here is that both anaesthetists are focusing on the technical aspects of needle insertion rather than, for instance, issues of patient comfort. (It is mostly their assistant who takes on the role of communicating with the patient, explaining what is happening.) There are outward markers of expert practice—such as the reference to the ‘feel’ of the needle and the confident statement that ‘the pain will go in a minute’ but the procedure was unsuccessful. Furthermore, their attempts continued for about 20 min before they opted to substitute general anaesthesia. In contrast, the consultant referred to above had greater skill but was paradoxically much readier to suspend his attempts at performing the block.

Fig 1

Extract from observation transcript.

Fig 1

Extract from observation transcript.

The extract in Figure 2 shows the further development of expertise. The trainee (A3) with 3 yr experience appears to relate to the patient more readily than his more junior colleagues in the excerpt presented above. When he cannot perform the spinal he promptly asks for help. The consultant who comes to assist him (A4) asks the patient to point to the middle of her back to help him locate the spinous processes, but otherwise appears to do the same as the trainee. His final comment, that it was ‘just luck’, may be true but may alternatively reflect the fact that his skills are so deeply embedded in his practice that he is not aware of them at the level they can easily be articulated.

Fig 2

Extract from observation transcript.

Fig 2

Extract from observation transcript.

The relationship between theoretical and practical knowledge

The typical initial path to learning regional anaesthesia—basic science followed by practical instruction—is outlined in this transcript excerpt:

‘Firstly I was shown the model of the spine and the spinal processes. It's important to have an idea of where you are putting the needle so you can visualise it in your mind. You've got to be familiar with the anatomy. Then it's a question of seeing, and then doing yourself. The first time I asked one of my colleagues to show me exactly what to do. He took me through it step by step. Then it's just seeing and doing.’

[Interview with trainee anaesthetist, 5 months' experience]

We observed some formal teaching in regional anaesthesia. The researcher's observation notes are shown in Figure 3. The tutorial was given by a consultant anaesthetist (A5) and a trainee of 5 yr experience (A6). There are two distinct types of knowledge in use here: (i) ‘explicit’, formal knowledge (basic anatomy and research evidence on applied pharmacology) and (ii) the practical aspects drawn from clinical experience (what to explain to patients beforehand and the language of ‘pops’ to describe the ‘feel’ of block insertion through evoking images of interlocking and fitting into place). It is evident that although the junior anaesthetist (A6) is familiar with obstetric epidural blockade in practice, his teaching on paravertebral blocks draws more on textbooks. The unambiguous instructions relating to safe practice in regional anaesthesia are worthy of note. Although much of this material is introductory, even the most inexperienced trainee would have had 5 months' experience of clinical anaesthesia, with many blocks, by the time this tutorial took place. However, the interview transcript above suggests that informal theoretical teaching had also taken place before the trainee had performed his first spinal.

Fig 3

Field notes from observation of tutorial on regional blocks for senior house officers.

Fig 3

Field notes from observation of tutorial on regional blocks for senior house officers.

As experience grows, the traditional teaching technique of demonstration followed by practice is seen. Practical demonstrations take place in the operating room, as in this transcript of the performance of a penile block:

  • A10 puts some gloves on.

  • A10 ‘..basically you go down to the symphysis pubis, go just below and off to one side…’

  • A11 picks up the 20 ml syringe (with orange needle) and feels where to inject. A11 also feels where to inject. They are both standing to the right of the patient, A11 parallel to abdomen, A10 to thighs. A11 unsheathes the needle, A10 says an orange needle isn't large enough.

  • A11 ‘a green?’

  • A10 ‘probably a blue’

  • A10 replaces the orange needle with a blue one. He explains where and how to inject.

  • A10 ‘some people say you feel a ‘pop’ through the fascia…’

  • A11 has inserted the needle and injected some.

  • A10 ‘now stop, come back and re-angulate…’

  • A10 repositions the needle, A11 continues the injection.

  • A10 ‘That's it’

  • A11 removes the needle, disposes it and his gloves and goes back to the patient's head.

  • [OB15 Consultant anaesthetist(A10) and senior house officer (A11), general surgical list]

Embedding and individualizing

Trainees may initially find the variety of different methods practiced by experts confusing (one had been shown four different methods of performing the same block in the first 6 months of his training). With time, however, they develop ‘personal’ techniques, deepening their knowledge of each block by learning, in the words of one of our respondents, ‘how it feels’, and acquiring a sense of what feels ‘normal’. The knowledge is not simply transferred from the expert to the trainee, it is ‘worked on’ by the learner and incorporated into his/her practice. Interweaving of practical experience and textbook material is seen again in the experienced trainee's account of how she would go about learning a new block (Fig. 4). Also in evidence is the need to spend time working on her own to get used to the technique. Her final comment encapsulated the expert's long-term familiarity with one technique and how that technique is described.

Fig 4

Extract from interview transcript.

Fig 4

Extract from interview transcript.

Discussion

In this study we have been able to start to characterize expertise in regional anaesthesia. Clearly this encompasses technical fluency, but moves beyond competence at needle insertion to incorporate unwritten strategies for increasing success. True mastery is also manifest in handling the patient (communicating, anticipating and minimizing discomfort) and recognizing the limits of safe practice (knowing when to stop trying). We suggest that the latter demonstrates what we call an ‘appropriate confidence’. It is probably no surprise that these elements of practice, which take the practitioner from simply competent to expert, are located in the non-technical or ‘affective’ domain of knowledge and skills. These have received growing attention in the past few years as investigators have begun to explore their significance for both assessment of trainees15,16 and the safety of anaesthetic practice.17–19 Though we have fewer data relating to how knowledge is acquired in regional anaesthesia, we are also able to offer, for further testing, an initial model. This seems to progress through the following stages: (i) the acquisition of anatomical fact; (ii) exposure to practical procedures under supervision; (iii) reflection and linking in new knowledge from experience to existing theoretical material; (iv) by means of working independently, continuation of this process; and (v) the incorporation of knowledge into personal ‘routines’ and styles, with the flexibility to adapt to cases which are out of the ordinary. Some previously published data from our larger study on anaesthetic expertise in general10 suggested that exposure to a range of techniques and independent working are both necessary to allow the individual learner to incorporate them into his/her own practice.

Previous work on training in regional anaesthesia has been largely quantitative and has concentrated on defining numbers of procedures required for the development of competence.4–6 In focusing on a small number of procedures in detail, we have tried to respond to Kopacz'20 concerns over judging competence by the number of attempts alone and his suggestions that more attention be paid to quality. We do not claim to be representative in any statistical sense. Qualitative methods such as this are more concerned with creating a valid representation of the phenomena under study, in this case the acquisition of regional anaesthesia skills and knowledge within their specific social context.21 Qualitative methods are often unfamiliar to anaesthetists but are generally considered appropriate when there is little prior knowledge of a subject, or when hypotheses are needed and we believe these preliminary observations advance our understanding of what ‘quality’ in regional anaesthesia from the practitioner's point of view might entail. We preferred handwritten notes to video recording as we considered that the presence of the researcher (previously an anaesthetic nurse in the study department) was less intrusive than a video camera, and thus less likely to cause practitioners to behave differently from normal.

Expertise in anaesthesia, in common with other fields, rests on the successful relationship between different forms of knowledge. Particularly important in the professions is the largely unwritten ‘tacit’ knowledge used by practitioners.22 Examples in this paper are the references to the ‘feel’ of procedures and the consultant asking the patient to confirm that he was feeling the bones in her back before attempting a spinal. It is often assumed that practical, tacit knowledge of a subject follows in a linear fashion from theoretical knowledge, but our data suggest that the acquisition of practical skills in regional anaesthesia actually builds on and refines the theoretical knowledge that went before. Practice thus provides the context for the theoretical knowledge as it becomes embedded in ‘skills’ and as the learner develops an appreciation of how the dimensions of regional anaesthesia practice (theoretical knowledge, patient care, manual dexterity, confidence, etc.) intersect. Our model is supported by educational theory (the experiential learning cycle23–26) and other notions of ‘reflection-on-action’.27

The difficulties of ensuring adequate training in regional anaesthesia have been well documented.2,3,28,29 It is clear to us that the clinical workplace provides the right educational forum and social milieu for learning the ‘total professional task’ of regional anaesthesia.30–32 Organization of training is clearly important in that theoretical material should precede first attempts at a block29 but revisiting theoretical material as practical experience grows should also be encouraged. A balance should be struck in the timing of supervised and independent attempts. Specifying a minimum recommended number for the commoner regional blocks29 is a helpful guide but we believe that creating the right educational climate can encourage ‘deeper level’ learning of reflection and explanation. Cleave-Hogg and Benedict33 have outlined how clinical teachers might promote greater complexity of thinking with which to understand and act on professional and life tasks and problems. Tweed and Donen24 have suggested an experiential model for the anaesthesia curriculum, constructed to expose trainees to the necessary clinical encounters to stimulate reflection and learning. Within this, seniors could attempt to convey their tacit knowledge by trying to articulate what they are thinking as they perform blocks or as they watch others do so. We hope therefore that what might be termed ‘art’ of expert regional anaesthesia will be preserved as anaesthesia moves towards competency-based training and assessment.

This small study highlights a number of questions for further study. A larger sample would allow our initial model of expertise development to be confirmed or refuted—particularly the idea that both exposure to a range of techniques and opportunities for independent working—and might also capture more of the tacit knowledge which usually goes undocumented. Our suggestions for the promotion of affective, non-technical skills should be evaluated formally. In particular, we would be interested to explore what changes in the anaesthetist's attitude to the task as experience develops, and how we might accelerate this and other aspects of the development of expertise.

The project from which this work arose was funded by the United Kingdom NHS North West Regional R&D Fund (‘The problem of expertise in anaesthesia’, project no RDO 28/3/05).

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Author notes

An abstract outlining the ideas elaborated in this paper was presented at the European Society of Anaesthesiologists' meeting in Nice, France, April 2002.

Comments

1 Comment
A personal insight into regional anaesthesia: authors' response
18 October 2006
Andrew Smith

We would like to thank Dr Singh for commenting on our paper. Whilst it adds to our arguments rather than criticising them, we would nevertheless like to offer the following observations.

First, Dr Singh’s letter demonstrates something we have noted many times. Once anaesthetists are made aware of the tacit elements of their practice, this seems to ‘unlock’ this knowledge for others to benefit from. One other situation we have seen it is where ‘interesting cases’ are discussed – more often than not, those present are eager to share their own personal experiences and nuances of technique. In our view, anaesthetic training would be enhanced by identifying and promoting such learning opportunities [1].

Second, those trained in biomedicine may be uncomfortable with the methods and findings of qualitative research, originating as they do from the social sciences. A common criticism is that it allows the researchers to impose their own views upon the subject they are studying, thus introducing a bias which ought not to be there. Whilst we have taken a number of steps to prevent this [2], one ‘acid test’ of the validity of the account produced by such research is how it resonates with others who are ‘in the know’. Thus it is gratifying to know that our work has struck such a chord in this reader.

Third, we agree on the clinical point that, whilst patient position is often specified in instructions about block insertion, the doctor’s is not. This may well contribute directly to the success of the procedure, as Dr Singh suggests, but we would also argue that it is important for the doctor to be comfortable as well as the patient. How often do we see anaesthetists bent over in awkward positions trying (often for some time) to perform a practical procedure? If the operator is relaxed and ergonomically positioned, one would expect work to flow more smoothly. But there is more to this than might meet the eye: in a related publication, Goodwin [3] analyses the spatial arrangements of anaesthetic work and its relationship to embodied knowledge. She shows how the careful positioning of practitioners, patients, tools and equipment actively shapes perception, and she discusses the implications for proficient practice.

Fourth, we hope that the College’s regional anaesthesia audit will enlighten the practice of neuraxial blockade in the United Kingdom, but would question whether such an investigation can capture the rich contextual detail which our in-depth qualitative work has reported. We see the two approaches as complementary. In our view, anaesthetic practice can, and should, draw on all possible ways of understanding in its quest for continual improvement in the quality and safety of care.

1 Pope C, Smith A, Goodwin D, Mort M. Passing on tacit knowledge in anaesthesia: a qualitative study. Medical Education 2003; 37: 650-5.

2 Smith AF, Goodwin D, Mort M, Pope C. Expertise in practice: an ethnographic study exploring acquisition and use of knowledge in anaesthesia. British Journal of Anaesthesia 2003; 91: 319-28

3 Goodwin D. Upsetting the order of teamwork: is 'the same way every time' a good aspiration? Sociology (in press).

Conflict of Interest:

None declared

Submitted on 18/10/2006 8:00 PM GMT