Anaesthetists understand their work in different ways.

Editor—We read with interest the investigation by Larsson and colleagues 1 reporting their qualitative study of how trainee anaesthetists understand their work. We congratulate them on their decision to pursue this type of enquiry. Only by addressing those aspects of anaesthetic expertise, which cannot be set out in syllabuses and measured as competencies, can a true picture of the complexity of our work be drawn. We have a few questions and would be interested to read the authors' responses. First, we liked the categories that the data suggested, but we wondered if the authors had thought of arranging them into any sort of hierarchy? (We note that they did so with the four categories which they used for experienced anaesthetists in their previous study. 2) In the Lancaster expertise study 3 we found that, as trainees gain experience, they seem to move from one level of understanding to another, which is not completely separate but rather incorporates and builds on what went before. Hence we suggest, in contrast to the findings of Larsson and colleagues, that changes to more comprehensive ways of understanding do in fact take place over time and this is brought about by the developing relationship between tacit and explicit knowledge. Furthermore, we would challenge the authors' assertion that their category F—where experience from patients is used to learn new things—is exclusive to trainees. One of our unexpected findings was the importance which 'fully-formed' experts attach to the potential for continuing learning from working with colleagues. 3 In the UK, there are moves to train non-physicians to administer anaesthesia. Central to this debate is the problem of how such practitioners might work, not only in the practical limits to their activities, but also in how they understand and conceptualize their work. We note that the first of Larsson and colleagues' transcripts refers to a trainee supervising a nurse and how he=she recognized when the nurse had a problem. We recognize that this is not directly within the scope of their work, but to what extent would the authors expect to see the same breadth of understanding in a nurse anaesthetist? Finally, we would endorse the authors' implication that defining different aspects of the anaesthetist's role will help trainees (and specialists) further their understanding. Although not a finding from our study, we have previously attempted to suggest a number of roles or styles related to anaesthetic practice. These …