Deference to expertise

Expert, expertise, local knowledge, knowledge of the circumstances - what do we mean when we defer to expertise? It is not so simple as it sounds. If you believe in it and use it then, yes, it works. But many people cannot make the leap of faith and believe we allow "freelancing," that is, we let the patients run the hospital. So ... what is it? What are the benefits of deference? How do we do defer safely?

Physicians have difficulty the concept of deference to expertise, as they believe it is their responsibility to manage all aspects of patient care (Paul Schyve, MD, Joint Commission, personal communication, December 2011). We also have the idea that means people can do what they like. They do not see it as local knowledge or specialty knowledge in a field other than medical care.

The main challenge in medicine is that physicians feel autonomous; they feel they have to be infallible. The system encourages this as the governance in the hospital is the physician and it is the physician who is ultimately accountable for patient care. This leads to rejection of suggestions and physicians appear to have a large ego. The commander of ship analogy is deleterious to patient care in medicine. This makes the physicians feel they have to be in control and they become emotionally defensive and protective from suggestions by fellow caregivers.

Sensemaking makes for a better approach, as there are no objections, rather suggestions, to improve sensemaking. We must break down the need for autonomy and infallibility in physicians and encourage system responsibility for patient care.

We independently use expertise in different manners. To teach endotracheal intubation, I brought together a medical expert from the hospital, a paramedic with field experience, and an educator who writes teaching objectives. Each one has an expertise component.

We have two ways of viewing ourselves- positive and negative. The negative tell us "I am not smart," "I am not correct," or “I cannot do this.” It takes time to train this out of people. We need the positive such as self-awareness, courage, and transcendence (the part of ourselves that helps each other). The positive will help people more freely say, "This is what I think." We need to listen to them because they are seeing things we have not seen before.

To assist in this I not allow people to introduce themselves as "just a student." I will comment, “She is ‘just the resident physician,” and “He is ‘just’ the nurse.” I close with, “I am ‘just’ the attending.” The adjective “just” is a low reliability word. I do not allow the word "just."

When you empower the little guy you will be surprised at what they bring. When someone with no power gives their opinion you learn more and that benefits the whole program.

It is a necessary balance, depending upon the amount of time you have, to draw out from people their own expertise but in the end you must put their words into proper terms and make a decision. Then interpret for all in the broader context. This takes knowledge and experience to translate their words into the terms needed for the team.

With deference to expertise you are not making a decision solely on the basis of your power and authority. You defer to a person on ground with knowledge and skill appropriate for the circumstances. But what happens when life or death situations occur? The authority gradient is so great the person with expertise may not be forthcoming.

The leader can make decisions and build barriers that people cannot speak through. In an educational system, one person had to have preapproval from the superintendent an area that the person was an expert in. This is because there is a rule. When a person makes their first decision things can go wrong. That will kill future initiatives not only for that student but everyone involved or who hears about it.



There must be willingness in the leader to give up control and defer to expertise. You must do this to defer to expertise. After you have deferred expertise, made a decision, and have given responsibility to the junior officer been the leader still maintains accountability and should not shoot the messenger if it does not work out.

Weick and Sutcliffe

HROs allow decisions to migrate up and down (Karlene Roberts, personal communication frequently). Migrating decisions up is not as much to keep authority central but to allow the operator the freedom to think unencumbered. Migrating decisions down gives responsiveness to the operator. Also, expertise is situational, not always related to the position in the organization’s hierarchy.