First, we liked the categories that the data suggested, but we wondered if the authors had thought of arranging them into any sort of hierarchy? (We note that they did so with the four categories which they used for experienced anaesthetists in their previous study.2)
In the Lancaster expertise study3 we found that, as trainees gain experience, they seem to move from one level of understanding to another, which is not completely separate but rather incorporates and builds on what went before. Hence we suggest, in contrast to the findings of Larsson and colleagues, that changes to more comprehensive ways of understanding do in fact take place over time and this is brought about by the developing relationship between tacit and explicit knowledge. Furthermore, we would challenge the authors' assertion that their category Fwhere experience from patients is used to learn new thingsis exclusive to trainees. One of our unexpected findings was the importance which fully-formed experts attach to the potential for continuing learning from working with colleagues.3
In the UK, there are moves to train non-physicians to administer anaesthesia. Central to this debate is the problem of how such practitioners might work, not only in the practical limits to their activities, but also in how they understand and conceptualize their work. We note that the first of Larsson and colleagues' transcripts refers to a trainee supervising a nurse and how he/she recognized when the nurse had a problem. We recognize that this is not directly within the scope of their work, but to what extent would the authors expect to see the same breadth of understanding in a nurse anaesthetist?
Finally, we would endorse the authors' implication that defining different aspects of the anaesthetist's role will help trainees (and specialists) further their understanding.
Although not a finding from our study, we have previously attempted to suggest a number of roles or styles related to anaesthetic practice. These are in no particular order and there may of course be others, but we offer them as a further contribution to the conceptualization of anaesthetic work:
1 Lancaster, UK 2 Southampton, UK
Concerning the structural relationship between the categories of description, we have in a previous study reported the different ways specialist anaesthetists understand their work. We described a work map with the understandings arranged in a hierarchical way.2 In the present study,1 trainee anaesthetists gave expression to four similar ways of understanding work (BE in the article). For the young trainees, anaesthesia work is still a fairly diffuse phenomenon and their ways of understanding are not as clear as those of specialist anaesthetists. We are convinced that the categories in the trainees' group are hierarchically related, but this is a result inferred from the previous study. However, understanding A, the novice, was not found among specialist anaesthetists and should be regarded as a lower level of understanding work than understanding B.
One result of our two studies is that the novice way of understanding was found only among the trainees. Obviously, young anaesthetists during training move from understanding A to B. They will meet situations were protocol driven anaesthesia will not work and they will be forced to take the step from understanding A to B, after considering the individual patient's physiology. In addition, all four types of understanding of the specialists were represented already among trainees, indicating that anaesthetists normally do not change their understanding during years of work. This is in line with the findings of educational research that competence development preferentially takes place within the confines of present understanding.5 To acquire a new way of understanding, confrontation with another's meaning (reflective dialogue) or meeting a provoking situation is necessary.6
The learner was the predominant way of understanding work for some of the trainees but for none of the specialist anaesthetists. In the phenomenographic method we used, only the predominant ways of understanding the phenomenon in question will be defined. Therefore the learner was not defined as a category in the study on specialist anaesthetists. We agree with Smith and colleagues that many anaesthetists do use experience from patients for learning.
The question about nurse anaesthetists is not within the scope of our studies and this part of our answer is my (JL) personal view. I believe that young nurse anaesthetists are, and should be, relying more on protocols and detailed guidelines, whereas experienced nurse anaesthetists can work independently considering the vast amount of tacit knowledge that they express in their work. The anaesthetist should, nevertheless, be very much present in the theatres of which he or she is in charge (usually two or three theatres at a time). This means going in and out at regular intervals, depending on what is going on in theatre and on the nurse's experience.
The object of phenomenography is to study the variation in which phenomena in the world are conceived of or understood. Our two studies tell us about two things: anaesthesia work as understood by anaesthetists, and the variation in the ways anaesthetists understand work. We do not regard the categories as a typology of anaesthetists. However, we do admit that some of Smith and colleagues' well-found metaphors of anaesthetist styles bear a clear resemblance to some of the categories in our studies.
Uppsala, Sweden
References
1 Larsson J, Holmström I, Lindberg E, Rosenqvist U. Trainee anaesthetists understand their work in different ways: implications for specialist education. Br J Anaesth 2004; 92: 3817
2 Larsson J, Holmström I, Rosenqvist U. Professional artist, good Samaritan, servant and co-ordinator: four ways of understanding the anaesthetist's work. Acta Anaesthesiol Scand 2003; 47: 78793[CrossRef][ISI][Medline]
3 Smith AF, Goodwin D, Mort M, Pope C. Expertise in practice: an ethnographic study exploring acquisition and use of knowledge in anaesthesia. Br J Anaesth 2003; 91: 31928
4 Klemola UM, Norros L. Analysis of the clinical behaviour of anaesthetists: recognition of uncertainty as the basis of practice. Med Educ 1997; 31: 44956[CrossRef][ISI][Medline]
5 Sandberg J. Understanding competence at work. Harvard Business Rev 2001; 79: 246
6 Marton F, Booth S. The path of learning. In: Marton F, Booth S, eds. Learning and Awareness. Mahwah, New Yersey, USA: Lawrence Erlbaum Ass, 1997; 13942