Educational Psychology Review

, Volume 5, Issue 3, pp 205–221 | Cite as

On acquiring expertise in medicine

  • Henk G. Schmidt
  • Henny P. A. Boshuizen


This article presents a new theory of expertise development in medicine and the empirical evidence available. This theory describes expertise development as the progression through a series of consecutive phases, each of which is characterized by functionally different knowledge structures underlying performance. The first phase is characterized by the accumulation of causal knowledge about disease and its consequences. Through experience with real cases, this knowledge transforms into narrative structures called illness scripts. The cognitive mechanisms responsible for this transition are: Encapsulation of elaborated knowledge into high level but simplified causal models or even diagnostic categories and tuning through the inclusion of contextual information. The third phase is characterized by the use of episodic memories of actual patients in the diagnosis of new cases. It is assumed that knowledge acquired in different phases form layers in memory through a sedimentation process. These knowledge sediments, although usually not applied any more in subsequent phases in the development of expertise, remain available for use when ontologically more recently acquired structures fail to produce an adequate representation of a clinical problem.

Key words

expertise development encapsulation contextual knowledge illness scripts 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. Allen, S. W., Norman, G. R., and Brooks, L. R. (1988).Effects of Prior Examples on Rule-Based Diagnostic Performance. Paper presented at the Annual Meeting of the American Educational Research Association, New Orleans.Google Scholar
  2. Anderson, J. R. (1983).The Architecture of Cognition Harvard University Press, Cambridge, MA.Google Scholar
  3. Anderson, J. R. (1987). Skill acquisition: Compilation of weak-method problem solutions.Psychol. Rev. 4: 92–210.Google Scholar
  4. Boshuizen, H. P. A. (1989).De Ontwikkeling van Medische Expertise; een Cognitief-Psychologische Benadering. (On the Development of Medical Expertise; A Cognitive Psychological Approach.) Doctoral dissertation, University of Limburg, Thesis Publishers, Haarlem, The Netherlands.Google Scholar
  5. Boshuizen, H. P. A., and Schmidt, H. G. (1992). The role of biomedical knowledge in clinical reasoning by experts, intermediates and novices.Cognit. Sci. 16: 153–184.Google Scholar
  6. Boshuizen, H. P. A., Schmidt, H. G., and Coughlin, L. D. (1987).On-Line Representation of a Clinical Case and the Development of Expertise. Paper presented at the Annual Meeting of the American Educational Research Association, Washington, D.C.Google Scholar
  7. Brooks, L. R. (1987). Decentralized control of categorization: The role of prior processing episodes. In Neisser, U. (ed.),Concepts and Conceptual Development Cambridge University Press, New York.Google Scholar
  8. Carey, S. (1985).Conceptual change in childhood. MIT Press, Cambridge, MA.Google Scholar
  9. Chi, M. T. H., Feltovich, P. J., and Glaser, R. (1981). Categorization and representation of physics problems by experts and novices.Cognit. Sci. 5: 121–152.Google Scholar
  10. Chi, M. T. H., Glaser, R., and Rees, E. (1982). Expertise in problem solving. In Sternberg, R. (ed.),Advances in The Psychology of Human Intelligence Erlbaum, Hillsdale, NJ, pp. 7–76.Google Scholar
  11. Chi, M. T. H., Glaser, R., and Farr, M. J. (1988).The Nature of Expertise. Erlbaum, Hillsdale, NJ.Google Scholar
  12. Claessen, H. F. A. and Boshuizen, H. P. A. (1985). Recall of medical information by students and doctors.Med. Educ. 19: 61–67.Google Scholar
  13. Coughlin, L. D. J., (1986). The Effect of Randomization on the Free Recall of Medical Information by Experts and Novices, M. A. Thesis, McGill University, Montréal, Canada.Google Scholar
  14. DeGroot, A. D. (1946).Het Denken van den Schaker. (Thinking Processes in Chess Players.) Noord Holland, Den Haag, The Netherlands.Google Scholar
  15. Feltovich, P. J. and Barrows, H. S. (1984). Issues of generality in medical problem solving. In Schmidt, H. G., and de Volder, M. L. (eds.),Tutorials in Problem-Based Learning Van Gorcum, Assen.Google Scholar
  16. Hassebrock, F., Bullemer, P., and Johnson, P. E. (1988).Wenn Less is More: Selective Memory of Problem-Solving Experts. Paper presented at the Annual Meeting of the American Educational Research Association, New Orleans.Google Scholar
  17. Hobus, P. P. M., Schmidt, H. G., Boshuizen, H. P. A., and Patel, V. L. (1987). Contextual factors in the activation of first diagnostic hypotheses: Expert-novice differences.Med. Educ. 21: 471–476.Google Scholar
  18. Hobus, P. P. M., Hofstra, M. L., Boshuizen, H. P. A., and Schmidt, H. G. (1988). De context van de klacht als diagnosticum. (The context of the complaint as a diagnostic tool.)Huisarts en Wetenschap 31: 261–267.Google Scholar
  19. Kintsch, W., and Greeno, J. G. (1985). Understanding and solving word arithmetic problems.Psychol. Rev. 92: 109–129.Google Scholar
  20. Laird, J. E., Rosenbloom, P. S., and Newell, A. (1986). Chunking in SOAR: The anatomy of a general learning mechanism.Machine Learn. 1: 11–46.Google Scholar
  21. Lesgold, A. M. (1984). Acquiring expertise. In Anderson, J. R., and Kosslyn, S. M. (eds.),Tutorials in Learning and Memory Freeman, San Francisco, CA.Google Scholar
  22. Lesgold, A., Rubinson, H., Feltovich, P. J., Glaser, R., Klopfer, D., and Wang, Y. (1988). Expertise in a complex skill: Diagnosing X-ray pictures. In Chi, M. T. H., Glaser, R., and Farr, M. (eds.),The Nature of Expertise Earlbaum, Hillsdale, NJ, pp. 311–342.Google Scholar
  23. Muzzin, L. J., Norman, G. R., Feightner, J. W., and Tugwell, P. (1983). Expertise in Recall of Clinical Protocols in Two Specialty Areas.Proceedings of the 22nd Conference on Research in Medical Education, Washington, D.C.Google Scholar
  24. Norman, G. R., Rosenthal, D., Brooks, L. R., Allen, S. W., and Muzzin, L. J. (1989). The development of expertise in dermatology.Arch. Dermatol. 125: 1063–1068.Google Scholar
  25. Patel, V. L., and Groen, G. J. (1986). Knowledge-based solution strategies in medical reasoning.Cognit. Sci. 10: 91–116.Google Scholar
  26. Patel, V. L., and Medley-Mark, V. (1986).Relationship Between Representation of Textual Information and Underlying Problem-Representation in Medicine. CME Report CME86-CS1, McGill University, Montreal.Google Scholar
  27. Patel, V. L., Arocha, J. F., and Groen, G. J. (1986a). Strategy selection and degree of expertise in medical reasoning. InProceedings of the 8th Annual Conference of the Cognitive Science Society Lawrence Erlbaum, Hillsdale, NJ.Google Scholar
  28. Patel, V. L., Evans, D. A., and Chawla, A. S. (1986b). Predictive versus diagnostic reasoning in the application of biomedical knowledge. InProceedings of the 8th Annual Conference of the Cognitive Science Society Lawrence Erlbaum, Hillsdale, NJ.Google Scholar
  29. Patel, V. L., Evans, D. A., and Groen, G. J. (1989). Biomedical knowledge and clinical reasoning. In Patel, V. L., and Evans, D. A. (eds.),Cognitive Science in Medicine: Biomedical Modeling MIT Press, Cambridge, MA., pp. 53–112.Google Scholar
  30. Peeck, J., Van den Bosch, A. B., and Kreupeling, W. J. (1982). The effect of mobilizing prior knowledge on learning from text.J. Educ. Psychol. 74: 771–777.Google Scholar
  31. Schmidt, H. G., and Boshuizen, H. P. A. (1992). Encapsulation of biomedical knowledge. In Evans, D. A., and Patel, V. L. (eds.),Advanced models of cognition for medical training and practice Springer Verlag, New York, NY.Google Scholar
  32. Schmidt, H. G., and Boshuizen, H. P. A. (1993).On the origin of intermediate effects in clinical case recall. Memory & Cognition, in press.Google Scholar
  33. Schmidt, H. G., Boshuizen, H. P. A., and Hobus, P. P. M. (1988). Transitory stages in the development of medical expertise: The “intermediate effect” in clinical case representation studies. InProceedings of the Cognitive Science Society Meeting Lawrence Erlbaum, Hillsdale, NJ.Google Scholar
  34. Schmidt, H. G., Norman, G. R., and Boshuizen, H. P. A. (1990). A cognitive perspective on medical expertise: Theory and implications.Acad. Med. 65: 611–621.Google Scholar
  35. Vosniadou, S., and Brewer, W. F. (1987). Theories of knowledge restructuring in development.Rev. Educ. Res. 57: 51–67.Google Scholar
  36. Voss, J. F., Greene, T. R., Post, T. A., and Penner, B. C (1983). Problem-solving skill in the social sciences. In Bower, G. H. (ed.),The Psychology of Learning and Motivation: Advances in Research and Theory (Vol. 17), Academic Press, New York, pp. 165–213.Google Scholar
  37. Whineburg, S. S. (1991). Historical problem solving: A study of the cognitive processes used in the evaluation of documentary and pictorial evidence.J. Educ. Psychol. 83: 73–87.Google Scholar

Copyright information

© Plenum Publishing Corporation 1993

Authors and Affiliations

  • Henk G. Schmidt
    • 1
  • Henny P. A. Boshuizen
    • 1
  1. 1.University of LimburgThe Netherlands

Personalised recommendations