Studying Tacit Knowledge in Anesthesiology

IN this editorial, the third in a series of four on excellence in anesthesiology, I will give a brief introduction to the concept of tacit knowledge and discuss how qualitative studies can clarify its role in anesthesia. The series was introduced by Andrew Smith, F.R.C.A. (Consultant Anesthesiologist and Honorary Professor, Department of Anesthesia, Royal Lancaster Infirmary, Lancaster, United Kingdom), highlighting the risk we take of losing sight of our professional work as a whole when we pay attention mainly to measurable competencies, and referring to his work examining how knowledge is acquired and used in anesthesiology. In the second editorial, Ronnie Glavin, F.R.C.A. (Consultant Anesthetist, Anesthetic Department, Victoria Infirmary, Glasgow, United Kingdom), discussed anesthesiologists’ nontechnical skills, which emerged as a result of a study based also on qualitative methodology. Both Smith and Glavin touch on skills and knowledge, which often develop in experts without their being fully aware of it. Here, after developing this concept of tacit knowledge, I will discuss the role of qualitative methods in research, and finally report on a study of how anesthesiologists think about their work, as an example of how qualitative studies can give us better tools for facilitating trainees’ development of tacit knowledge. In the reductionist view of teaching, the best way of understanding a complicated phenomenon is to reduce it to its component parts and add to this a set of rules, explaining how the parts relate to each other. This way of thinking, which has long been predominant in medical education, is linked to the logical positivist tradition, where the underlying assumption is that we can have knowledge only about that which can be formulated in written text and which can be proven by formal methods. Consequently, the focus has been on factual knowledge: principles, theories, and facts presented in textbooks and formal lectures. However, the complex work of anesthesiologists has this other dimension of knowledge and skills, which can be acquired only through training, experience, and reflection. It is an aspect of knowledge that has been named the tacit dimension by Michael Polanyi, scientist and philosopher of science, in his book of the same name. By tacit knowledge, we here mean knowledge that cannot be described by using propositional statements (statements that can be defined as true or false). If tacit knowledge is thought of at all, it is sometimes thought of as an inferior form of knowledge, but, according to Polanyi, it instead represents a higher level of knowledge, integrated and ready to be used. The step from explicit to integrated knowledge is necessary for the development of clinical proficiency. Integrated knowledge means that the knowledge includes a tacit dimension; it can be seen as the whole at one glance and can be used subconsciously without being deliberately focused on. The way knowledge is usually presented in textbooks—structured, in logical order, sometimes as algorithms—is of little value in giving the knowledge a tacit dimension. Reaching this dimension is instead a question of the knowledge changing from being open and explicit to a state where the knowledge can stay in the background but, as an integrated part of the professional, can nevertheless guide our management of a clinical phenomenon or situation. The tacit dimension of knowledge cannot be straightforwardly described, but we can observe the result of it. Expert anesthesiologists’ ability to act correctly and at times uncannily fast in difficult and uncertain situations is but one example. It is based on the anesthesiologists having internalized formal knowledge after reflection on clinical situations. In acute situations, when time is short, they can use analogous situations from their experience to guide their action. Reflection, therefore, is an essential element of training in anesthesiology. However, some anesthesia trainees see their training predominantly as a matter of learning rules and guidelines. These trainees need to understand that work is just as much about managing a large repertoire of clinical situations. They must let go of the feeling of security that they get from explicit knowledge. Rules are helpful in the anesthesiologist’s work, but rule following without tacit knowlAccepted for publication August 27, 2008. The author is not supported by, nor maintains any financial interest in, any commercial activity that may be associated with the topic of this article.