Thinking Out Loud: Expertise and the Pandemic

A frequent model, consistent with the journey from apprentice to master, defines stages of progress marked by increasing automaticity. The “in-the-flow” of an accomplished individual where actions are both “intuitive and effortless,” the “knowing-how” rather than the “knowing-that.” Given a novel situation, expertise based on knowing-how falters. 

Another model attempts to consider the expertise of experience. To my mind, this more aptly characterizes the transition from journeyman to master. The journeyman has the requisite “knowing-how” and begins to learn how to improvise and respond to the unexpected, frequently reflecting upon their past actions to learn and improve for future situations. When confronted by the novel, these experts develop an ability to transition from automaticity to in-the-moment reflection – they can name and frame a problem, a process requiring more effort than whatever advantages automaticity might supply.  

Yet, a third model attempts to distinguish between experienced non-experts, well trained in the skillset of automaticity, who struggle in the face of the novel because they unthinkingly fall back on the skills they know. And experts who possess the deep knowledge that makes navigating the complex and unusual. Those experts engage in the same in-the-moment reflection mentioned previously but do so continuously, even for the routine tasks – making the ability to transition from automatic to reflective, dare I say, automatic.

Expertise is a dynamic process involving a balance between automatic and effortful processing. The ability to slow down when necessary, recognize the limitations of automatic responses, and engage in thoughtful reflection is a defining characteristic of expertise.

Slow Down, You Move Too Fast

Because of the automaticity of some behavior, expertise reduces our cognitive load, freeing up resources to maintain a broader attentional focus, allowing an expert to identify cues that signal the novelty of the situation and the need to slow down and transition to a more effortful reflection. Experienced non-experts cannot widen their attentional focus and miss the clues that they are entering uncharted territory. They attempt to force-fit the situation into a familiar pattern, leading to errors in judgment.

Situational awareness is the ability to accurately perceive and comprehend the elements of a situation, understand their meaning, and predict their future status. This ability is crucial for effective decision-making in dynamic environments. Experts are more adept at recognizing ill-defined problems, defining their boundaries, and placing them within a broader context for effective decision-making, giving them names and frames. Experienced non-experts struggle with this process, either failing to recognize or misframing the problem, leading to inadequate solutions.

The sources offer several illustrative examples to highlight these differences:

• Medical Diagnosis: An experienced non-expert emergency physician encountering a patient with abdominal pain and diarrhea might quickly diagnose gastroenteritis based on pattern recognition. An expert, however, might detect subtle inconsistencies in the presentation, prompting them to slow down, consider alternative diagnoses like intestinal ischemia (loss of the blood supply to the intestines, a surgical emergency), and order further investigations.
• Surgery: A surgeon operating in a largely automatic mode might encounter an unexpected anatomical variation. An expert surgeon would likely sense the increased difficulty, shift their attention, and engage in a more deliberate, problem-solving approach. An experienced non-expert might miss these cues or persist with the initial strategy, potentially leading to complications.

The COVID-19 pandemic presented a complex and evolving situation with significant scientific uncertainty, political pressures, and rapidly changing information. Let’s consider two competing approaches, those taken by the CDC and those proposed by the Great Barrington Declaration (whose authors and associates are set to take the reins at the CDC). Assessing the CDC's performance requires a nuanced approach considering these contextual factors.

• Situational Awareness: A key question in evaluating the CDC's response is whether they exhibited adequate situational awareness during the pandemic. Did they accurately perceive the emerging threat of COVID-19, comprehend its potential impact, and make accurate predictions about its future course? 

I would think that the perceived threat was under and then over appreciated. This was partly due to an evolving data set regarding infectivity and mortality that became more certain as more people became ill. It is difficult to argue that the CDC was not slow in recognizing and acting upon newly emerging information, but they did. Conservatism of action is an institutional response incorporating the essence of “Do No Harm.” 

• Slowing Down When Necessary: Did the CDC demonstrate a willingness to pause, reassess, and adjust its strategies as the pandemic unfolded, even if it meant deviating from established protocols or challenging conventional wisdom? Certainly not initially, and arguably, not at all. 

While I have felt, as a clinician, that they did the best they could with a challenging and changing viral opponent and with limitations externally imposed by politics on both sides of the aisle, I have never heard them say they were wrong. More importantly, they have not afforded themselves the reflection that time allows to more fully consider where they may have erred. 

• Naming and Framing: Did the CDC effectively identify the key challenges posed by COVID-19, communicate them clearly, and frame the problem to facilitate effective action? Not at all. 

The Great Barrington Declaration (GBD) called for "Focused Protection" against COVID-19, advocating for those at minimal risk of death from the virus to resume their everyday lives. At the same time, measures were to be implemented to protect those deemed most vulnerable, all resolving in the arrival of herd immunity.

• Situational Awareness: The GBD emphasized the differential mortality risk between the young and old, focusing on the lower risk for children and advocating for a return to normalcy for those deemed less vulnerable. This focus on short-term mortality risk, potentially at the expense of broader health considerations, i.e., Long COVID, indicates a limited scope of attention and an incomplete understanding of the situation's complexities. The GBD's emphasis on a rapid return to economic normalcy, without fully considering the evolving understanding of the virus and its long-term effects, aligns with an incomplete understanding of the virus’s dynamic nature.
• Slowing Down: The GBD advocates for a rapid and decisive shift in strategy, urging an immediate return to normalcy for those not considered vulnerable, primarily emphasizes what were known factors, and doesn't advocate for slowing down the proposed policy shift to account for evolving scientific understanding. This raises questions about whether sufficient time and consideration were given to potential unknowns or the potential for changing circumstances. 
• Naming and Framing: The GBD frames the problem of COVID-19 primarily around the immediate economic and social costs of lockdowns and restrictions, arguing that these costs are unsustainable and disproportionately harm the underprivileged. While these concerns are significant and warrant consideration, the GBD's framing downplayed the potential health risks of widespread infection, particularly to vulnerable populations. 

Conclusion

I am forced to conclude that neither the CDC nor the authors and advocates of the GBD acted as we might hope from medical experts. Both acted more as experienced non-experts, focused on their familiar solutions, and both failed to, if not recognizing the unique situation presented by the COVID virus, then were unable to develop plans that took uncertainty and change into account. The GBD authors and advocates, like the CDC, have failed to acknowledge the weakness of their arguments when faced with the real-world outcomes we experience. 

Moving forward, I have little hope that the new “disruptive” leadership characterized by the GBD will bring any new expertise to our federal health institutions. They may bring new theories, but theories, disruptive or not, are not actions. The putative new leadership shares the same leadership skills and limitations they decry in those exiting the stage.