Adaptive Expertise: Between Familiar and Novel Problems

Expertise for Performing Familiar Procedures and Responding to Novel Situations

Adaptive expertise encompasses both the ability to solve familiar problems efficiently and the ability to adapt knowledge and solutions to novel problems. In clinical settings, it emerges as practitioners respond to unexpected findings, patients’ complex needs, and changing conditions of care while following guidelines. This requires knowing the procedure, understanding why it works, and being able to re-examine current judgments.

Individuals, Tasks, and Environments Connecting Adaptive Expertise and Adaptive Performance

A literature review synthesizes definitions, theoretical models, and associated characteristics of adaptive expertise and adaptive performance in educational and workplace settings (Pelgrim et al., 2022). The research team conducted an overview of reviews to extract and synthesize findings from existing literature reviews, searching Scopus and Web of Science in April 2021 for literature published from 1986 onwards. Duplicates were removed using EndNote, and the remaining records were screened with Rayyan. Two researchers independently reviewed each article, with a third participating when disagreements arose. After duplicates were removed from the 3,117 retrieved records, 2,259 were screened, and 97 articles underwent full-text review—excluding 12 inaccessible articles from the 109 that met the criteria—yielding 9 articles for the final analysis. All were English-language journal articles. Of these, 2 addressed education, 5 addressed the workplace or both education and the workplace, and 2 did not specify a context. Three researchers participated in data extraction. The assumptions underlying the interpretations were reviewed in 3 discussions with consortium stakeholders representing 11 higher education institutions in the Netherlands.

The literature used adaptive expertise in educational contexts and adaptive performance or performance adaptation in workplace contexts. Adaptive performance was defined as adaptive expertise manifested in an observable form. The diagram connecting the two concepts does not imply a linear or causal relationship. The literature commonly emphasized responses to changes in tasks or environments. These ranged from learning tasks novel to the individual to events novel to the entire world. Theoretical models differentiated task complexity at the levels of components, coordination, and dynamics, or explained how data are reinterpreted and goals and methods adjusted. Procedural knowledge and conceptual knowledge for understanding why solutions work were central to explanations of transfer to unfamiliar situations.

Associated characteristics were categorized as individual, task, or environmental factors. Individual characteristics included domain knowledge and skills, cognitive flexibility, learning orientation, self-regulation, self-efficacy, openness, and reflection. Task and training characteristics included ill-structured, non-routine problems, diverse cases, decision-making autonomy, deliberate practice, hypothesis testing, learning from errors, and collaborative problem-solving. Environmental characteristics included supportive supervisors, peer support, knowledge sharing, team learning climate, mentoring and feedback, and authority to explore. Job uncertainty was also reported to have a negative impact. This list synthesizes empirical research and theoretical reasoning. Characteristics such as self-regulation function both as conditions supporting development and as traits expressed in performance. These roles require distinct interpretations. The review selected studies using search terms focused on individuals. Peer support and team learning climate were therefore treated as environmental conditions supporting individual development. Proposals for further research included longitudinal studies, synthesis of scales and items, guided workplace exploration, and research in simulated work environments.

Knowledge Utilization and Judgment Re-examination Combined with Reflective Practice

A theoretical paper advocating the combination of adaptive expertise (AE) and reflective practice (RP) examines changes to healthcare professionals’ roles and care practices during the pandemic (Ng et al., 2022). The research team compared the histories and pedagogies of the two traditions, developed a case involving a patient awaiting transition to a long-term care facility, and proposed an educational design. The “optimal adaptability corridor” of AE describes the balance between performing familiar procedures efficiently and developing new solutions. The pedagogies included integrated instruction linking clinical concepts with basic science mechanisms and meaningful variation that exposes learners to conceptual differences through contrasting cases. They also included productive failure, in which explanations follow an initial attempt at problem-solving. RP is an epistemology of practice concerned with examining personal understanding and behavior in situations of uncertainty and conflicting values. Critically reflective practice also considers the influence of power and hierarchy on knowledge and practice. Arts-based education, dialogue, guided reflection, and reflective writing were discussed as pedagogies for examining different experiences and judgments.

The patient in the case, Samuel, is an 85-year-old man with early Alzheimer’s disease and hearing loss. His cognitive and physical functioning and capacity for self-care declined following a prolonged hospitalization for COVID-19 complications. In a class applying AE, students first draft a care transition plan and compare it with an expert’s plan. They learn how a history of delirium and medication reviews inform judgments. Explanations link medication mechanisms to clinical effects. Collaboration, communication, and team dynamics are addressed as foundational knowledge for interprofessional practice. From an RP perspective, the case is expanded to include staffing shortages in long-term care, visitation restrictions, the family’s caregiving circumstances, and staff members’ moral distress. Students read about and discuss the experiences of residents and family caregivers, and observe how systems affect care during clinical practice.

A class combining both approaches centers on faculty and patient instructors sharing experiences from long-term care settings. Student teams receive additional, differing preferences from the patient and family as they develop a discharge plan. Students adjust the plan while examining profession-specific priorities and institutional conditions. After students attempt to solve the problem, instructors offer explanations and questions to help them examine the assumptions underlying judgments and social norms. Instructors’ willingness to express uncertainty and create psychological safety helps establish the conditions for participation in productive failure. The authors emphasized that combining AE and RP calls for examining educational purposes, epistemologies, pedagogies, and assessments together to ensure philosophical coherence. The possibility that reflection assignments could prompt perfunctory responses or a sense of being surveilled was also considered. Preparation for future learning assesses performance in learning and applying new information. Its use in RP research leaves a question of how to assess re-examination of knowledge sources and power relations in line with educational purposes.

Adaptive Practice Amid Uncertainty and Supervisory Relationships Among Emergency Department Residents

A cognitive ethnographic study exploring the conditions under which adaptive practice emerges in clinical care observed PGY-1 residents in the emergency departments of a Danish university hospital and a regional hospital (Gamborg et al., 2024). The participants were 27 residents (19 women, with an average of 1.5 months of training experience), who treated 32 older patients. Patients were eligible for inclusion if they were over 60 years of age. One 60-year-old patient was also included because multimorbidity and frailty made the case relevant to geriatric care. The research team collected 80 hours of observational data between 7:00 AM and 10:00 PM from August 2019 to December 2020. They checked their understanding of residents’ thinking through conversations typically lasting 5 to 20 minutes at times that did not interrupt care. From a distributed cognition perspective, interactions with people, tools, and culture were tracked from notification of a patient’s arrival through diagnosis and treatment planning. Behavioral indicators included epistemic distance, or stepping back from existing understanding; self-regulation, or identifying and responding to knowledge gaps; and orientation to novel content, or treating new material as an opportunity to learn. Observational narratives were analyzed at the levels of actors (the people and tools involved in interactions), moderators (material, cognitive, and social conditions), and consequences (the results).

Adaptive practices were observed in all 27 residents, with individual residents alternating between routine and adaptive practices depending on the situation. Electronic health records and medical handbooks were used to assess existing knowledge and determine next steps. Questions and information from patients, families, and nurses revealed knowledge gaps and sometimes interrupted decision-making. Uncertainty manifested in additional testing and verification. Residents explored more proactively when attendings worked with them to identify knowledge gaps and reflect on the rationale for judgments. Dependence and verification behaviors increased during interactions involving repeated questioning of decisions or authoritative interventions. Behaviors that turned new content into learning opportunities were rarely observed. Some residents tracked final diagnoses by saving records of difficult patient cases or accompanied specialists during clinical care. Perceptions that expressing emotions was unprofessional and that residents were expected to perform like experienced physicians also influenced how they handled uncertainty.

In one case, a resident with less than 1 month of training took the history of a 91-year-old woman presenting with dyspnea. The interview became chaotic as blood draws and repeated attempts to insert a urinary catheter increased the patient’s pain and frustration. As subsequent consultations centered on relaying the attending’s instructions, the resident began verifying every decision. Because both emergency departments required residents to consult an attending physician on treatment plans for all patients, help-seeking is best interpreted in light of this obligation and residents’ participation in clinical judgments. A supervisory culture that supports accepting uncertainty as part of professional practice was proposed. Entrustment, resident initiative, and education on handling uncertainty were discussed in workplace-based assessments using EPAs.

Reading notes

The same request for help may enable further exploration after a knowledge gap is identified or serve to verify decisions in an environment where consultation is mandatory. Interpretation of the results depends on the study’s use of observation and conversation to infer cognitive processes, its focus on cases involving older patients, and a clinical structure in which PGY-1 residents do not bear full responsibility. In research connecting HRD and graduate medical education, the conditions under which solving work problems leads to learning can be examined by analyzing consultations in which attendings and residents jointly synthesize information and explain the rationale for their judgments.

References

• Gamborg, M. L., Mylopoulos, M., Mehlsen, M., Paltved, C., & Musaeus, P. (2024). Exploring adaptive expertise in residency: The (missed) opportunity of uncertainty. Advances in Health Sciences Education, 29(2), 389–424. https://doi.org/10.1007/s10459-023-10241-y
• Ng, S. L., Forsey, J., Boyd, V. A., Friesen, F., Langlois, S., Ladonna, K., Mylopoulos, M., & Steenhof, N. (2022). Combining adaptive expertise and (critically) reflective practice to support the development of knowledge, skill, and society. Advances in Health Sciences Education, 27(5), 1265–1281. https://doi.org/10.1007/s10459-022-10178-8
• Pelgrim, E., Hissink, E., Bus, L., van der Schaaf, M., Nieuwenhuis, L., van Tartwijk, J., & Kuijer-Siebelink, W. (2022). Professionals’ adaptive expertise and adaptive performance in educational and workplace settings: An overview of reviews. Advances in Health Sciences Education, 27(5), 1245–1263. https://doi.org/10.1007/s10459-022-10190-y