In Pursuit of Excellence Reconsidered: Expertise and Expert Performance in the Teaching, Learning, and Application of Anatomy

Physician training is built on a model that frames development as moving from novice to expert through a series of milestones, measurable competencies, and outcomes (Epstein and Hundert, 2002; Leach, 2002; Carraccio et al., 2008; ten Cate et al., 2010; Holmboe et al., 2016; ACGME, 2018). One well-known articulation of this framework, the Dreyfus Model, stages the individual from novice to advanced beginner to competent, proficient, and then expert (Dreyfus and Dreyfus, 1980). Within medicine, continuing professional development (CPD) and the expectation that medical professionals will be held accountable for knowledge and skills improvement is a mainstay of their expertise (Leach, 2002; Ericsson and Pool, 2016). To this end, a focus on practice with measurable outcomes and feedback is considered cornerstone for determined competency. On the contrary, while it may be natural to assume experience (number of years in practice) to be a proxy for expertise, studies have shown these to have a consistent negative relationship (Ericsson, 2004; Durning et al., 2010). In light of such findings, medical educators stress the role of deliberate practice in validating the development of expertise (Ericsson, 2004; Causer et al., 2014; Ericsson and Pool, 2016). As long as the practice of medicine continues to maintain a sorority with basic sciences (Sbayeh et al., 2016) authentic expertise as it relates to scientific, clinical, and technological advancement as well as the evolving social needs of the patient, the responsibility for up-to-date-expertise becomes an imperative for all professionals (Turney, 2007; Burgess and Ramsey-Stewart, 2015). Within such an environment, basic science education has to meet current practice demands by evolving into “authentic learning” practices that emphasize teamwork, leadership, interprofessional learning, and reflection (Pawlina and Drake, 2016). In the current teaching and learning environment expert productivity, deliverables and formal evaluation have become imperatives governing much of what we do and how we perform as teachers, facilitators and anatomists. For many anatomy educators, student evaluations of teaching have stood as the “grim reaper” for quality improvement. Despite the growing evidence questioning the reliability of student feedback (Uttl et al., 2017; Mullikin et al., 2019), its impact as a measure of faculty teaching performance remains the default standard for most; mainly because it is the only metric available or used by many departments and institutions. Often instructors who are more likable, charismatic, animated, or entertaining receive disproportionally better evaluations (Delucchi, 2000; Titus, 2008). In the absence of other objective metrics and under unremitting pressure from university administration, instructors may be unduly inclined to accentuate the entertainment value in course delivery at the expense of knowledge, expertise, and pedagogy; or to inflate grades, since students with higher grades are more likely to provide more positive feedback on teaching (Adams and Umbach, 2012; Rowan et al., 2017). While student perceptions of teacher effectiveness must not be discounted as a driver for self-improvement, it is essential to reflect on what it may take to establish, maintain, and uphold professional identity within an expertise in the complex embodiment of what it means to become an “expert.” In the context of the professions of anatomical sciences, the debate continues to gain momentum with arguments for and against such CPD expectations (Rizzolo and Drake, 2008). Within the diverse field of anatomical sciences, no one benchmark can, or should, be applied. Furthermore, standardization of knowledge competency with congruent pedagogic skills (Berman, 2015) will be met with challenge and not surprisingly, resistance. In the realm of anatomy education, it is easy to lose sight of the fact that familiarity of subject content, if left unchallenged, can impose a deceptive sense of assurance in delivery of expertise. As a subject, anatomy has the propensity for perpetuating a mentality that once learned the knowledge is good forever. In the current climate, students, scientists, public domains no longer depend on professors for information strengthening the notion that “everyone is an expert.” This sense of confidence while empowering for many outside the profession of anatomy, may at the same time be foreboding to its scientific and academic rigor. Within the profession, it is no longer sufficient to be satisfied with status quo, nor is it progressive to foster an erroneous sense of identity that if left unchallenged, can promote a reign of self-imposed mediocrity or a sense of all knowing and self-importance. The current professional environment however continues to prove time and time again that anatomy no longer exists as a predetermined science (Eizenberg, 2015). In the study and application of anatomy, audience, emphasis, curricular placement, and expertise required to interpret its content continues to transform, keeping the bar for required expertise in constant flux. In reality, the very progressive spirit of 21st century thinking appears to have circumvented the invaluable role that deliberate practice, critical analysis and reflection have to play in establishing expertise. Simultaneously, the “commodification” of science and the ability to harness large research grants sometimes undermines pedagogic rigor through a different metric but by its very nature, the field of anatomical sciences is built through mentorship and hands on experience underpinned by a commitment to continued learning and improvement of knowledge and skills. This is further fostered by interactional expertise (Collins and Evans, 2002), which can be acquired by “deeper immersion in the linguistic discourse” of the applicable scientific field (e.g., medicine, forensic science, surgery, biomedical sciences). In the academic environment difficulty in securing experts who not only are able to competently deliver a demanding subject, but also provide context to the clinical and scientific application of the subject material is a tangible impediment (McCuskey et al., 2005; Doss and Brooks, 2016). While not academically desirable, it is no longer uncommon for new anatomy graduates to be prematurely catapulted to levels of expert roles that may require greater skill sets and knowledge at which the level of proficiency may not provide. At the same time, the consistently evolving teaching and learning environment and generational shift in student cohort and associated expectations challenges existing anatomy professoriate to rethink, adapt, and innovate (Schaefer et al., 2019). Nonetheless, while most have done well through self-driven efforts, in the absence of any recertification/CPD requirements or opportunity to gain accreditation and advance anatomical knowledge, the impetus, and momentum for enhancement of expertise diminishes. The profession of anatomy is starting to see trends toward establishing a set of standards that would govern how individuals reach, establish, and maintain expertise in anatomical content, pedagogy, and education research. More emphasis is directed toward training of future anatomists in education-focused programs where students conduct rigorous evidence-based education research (Brokaw and O’Loughlin, 2015) and by engaging present anatomists in the scholarship of teaching and learning (O’Loughlin et al., 2019). In fact, there is mounting interest and evidence of professional societies commitment in supporting this effort e.g., American Association of Anatomists (AAA), American Association of Clinical Anatomists (AACA), Anatomical Society (AS) in UK, International Federative Association of Anatomists (IFAA) to enable both early and established career members to participate in formal learning sessions and to further develop expertise through collaborative training programs, postgraduate courses, and funded visiting professorships (Fraher and Evans, 2009; O’Loughlin et al., 2019). As a journal, Anatomical Sciences Education unifies these efforts by striving to maintain custodianship of its content through vigorous peer review and editorial oversight. In an effort to provide a platform for self-directed academic enhancement, the journal is purposeful in its selection of manuscripts so as to align global practices and provide opportunity for remote peer teaching, learning, and education research within the professional framework (Pawlina and Drake, 2010). While akin to medical practice in which expertise is built on deliberate practice, expertise in the anatomical sciences may be more appropriately constructed on deliberate performance – an activity defined by the “effort to increase domain expertise while engaging in routine work activity” (Fadde and Klein, 2010; Norman et al., 2018; Stigler and Miller, 2018). Applying features of deliberate practice (i.e., dissection performance, targeted study of core anatomical knowledge and its relevance to practice), deliberate performance (i.e., active teaching, student interaction, content delivery, hands on laboratory instruction) can be enhanced through several targeted approaches including mentorship, scientific avenues, and professional platforms (Streeter, 2014). Generating and enhancing relationships with peers and colleagues will create a diverse network of sponsors eager to help you succeed (Sulaiman et al., 2016). Even for anatomists whose practice may remain behind closed doors where teaching and learning co-partnerships are not accessible, the era of incentivized, media-driven, web- and electronic-based informational platforms, makes access to information empowering. As anatomists, our responsibility lies in service; through the promotion and innovation of teaching and learning, through the advancement of clinical practice, and through the curatorship of its science. To be satisfied with individual status quo is simply not good enough. In the absence of formal expectation, the drive for self-improvement in whatever form it may take is crucial to the maintenance of the collective profession and its science.

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