Functions of Expertise in a Medical Intensive Care Unit

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This paper examines physician expertise in a hospital medical intensive care unit and illustrates three functions that expert physicians perform : (1) pursuit of ill-structured goals ; (2) treatment of dynamic disease processes in individual patients ; and (3) detection and ownership of problematic circumstances. These functions of medical expertise are illustrated using examples from videotapes of physician activities collected over five days in an inner city teaching hospital, providing the basis for the following hypotheses. Goal-directed reasoning in this domain extends beyond the technical foundations of medicine to the cultural values that acknowledge its expertise (Agnew et al. 1994). The treatment of dynamic disease processes depends on the adaptation of accepted methods to individual differences among patients, according to known symptoms and diagnoses. Diagnosis is a subgoal to treatment, pursued at multiple levels of abstraction, and only when it is not superseded by more urgent treatment goals. Problem ownership—the acceptance of a problem as medical and suitable for treatment—requires medical knowledge and an awareness of the distribution of technical knowledge and responsibilities throughout a health care organization. These hypotheses provide a functional specification of physician expertise, and the foundation for a test of proficiency claimed by humans or machines.



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