1234
burns 40 (2014) 1232–1243
based on our prior studies [1]. As already stated pore sizes of these microfiber scaffolds are not a barrier to rapid cell infiltration as seen in this study. The authors also suggest that it will be necessary to orientate the skin pieces. We considered this initially but our pilot work showed no advantage in orienting these very small skin pieces in theses scaffolds. Unlike Meek grafts the skin will be finely minced and placed onto scaffolds and not placed directly onto a raw wound bed in vivo. Thus all skin pieces will be in contact with a large surface area of scaffold and we have in this preliminary study shown that skin cells are able to migrate along the fibres of the scaffold irrespective of their initial orientation and then reform a continuous epithelial barrier. Also in our recent study with limbal pieces we found the initial orientation of the tissue pieces did not influence the outcome. In summary while laboratory expansion of keratinocytes has a valuable role to play in helping surgeons restore a skin barrier for patients with extensive burns it will always be expensive and take time. Also epithelial cells alone do not solve the problem of how to replace the dermis and so far the challenges of a one-stage epidermal/dermal skin reconstruction remain tantalizingly close but not yet realized. In this preliminary study we suggest an approach for small-scale reconstructive surgery, which we think merits further investigation, and we thank the authors for their constructive comments.
Conflict of interest No conflicts of interest.
references
[1] Blackwood KA, McKean R, Canton I, Freeman CO, Franklin KL, Cole D, et al. Development of biodegradable electrospun scaffolds for dermal replacement. Biomaterials 2008;29(21):3091–104. [2] Glowacki JMS. Collagen scaffolds for tissue engineering. Biopolymers 2008;89(5):338–44. [3] Despande P, Sefat RC, Mariappan F, Johnson I, McKean C, Hannah R, et al. Simplifying corneal surface regeneration using a biodegradable synthetic membrane and limbal tissue explants. Biomaterials 2013;34:5088–106.
Kavita Sharma* Sheila MacNeil The Kroto Institute, University of Sheffield, North Campus, University of Sheffield, Broad Lane, Sheffield S3 7HQ United Kingdom *Corresponding author E-mail address: [email protected] (K. Sharma)
Letter to the Editor Comment on: Burn care experts and burn expertise Sir, We read this article with interest but feel compelled to address some of the points raised [1]. Expertise has to be measurable. If the concept of end-of-training examinations to enter onto a specialist register is not sufficient, consider the task a lawyer must face when qualifying a witness as an expert for the delivery of opinions in court. The concept of an expert must be definable and distinguishable from the role of a commentator. Whilst we agree that to some extent, expertise is a form of knowledge, the roles of education and experience are symbiotic rather than mutually exclusive. Indeed in surgical practice they nearly always go together, where expertise develops both theoretical and practical, applied knowledge. The suggestion that ‘‘experience obviates the need for conscious effort’’ [1] implies that experts molding treatment strategies in often complex burn cases do so with passive ease and little active thought. To state that ‘‘experts have an intuitive grasp of situations based on deep understanding and a repertoire of responses’’ [1] overlooks the use of evidence-based medicine in daily practice. Judgments, rather than becoming ‘‘effortless intuition’’[1], are made by experts based upon the evidence of best practice and whilst clinical scenarios may be familiar, one must distinguish between perception and that which is a wellinformed and balanced decision for the benefit of the individual patient. It is this continual appraisal of current practice with the growing evidence base that contributes to the development of expertise. The breadth of references within Al-Benna and O’Boyle’s paper – 33 of 36 were personal references – might reflect that the authors’ opinion differs from our own. Al-Benna and O’Boyle argue that burn care expertise is narrowed by sharing out the different phases of patient burn care between professionals, from resuscitation to rehabilitation [1]. We would suggest that, quite to the contrary, burn expertise is actually broadened by such measures, equipping professionals with the cumulative experience and in-depth understanding of current literature to deliver the optimum care available to patients throughout their burn treatment. The consideration that dividing burn care expertise results in less reliable judgments undermines the value of the well-established and valuable multidisciplinary structure of burn care. Yours faithfully,
Conflict of interest statement There are no conflicts of interest, financial or otherwise, associated with this work.
Accepted 21 January 2014
reference http://dx.doi.org/10.1016/j.burns.2014.01.016 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved. [1] Al-Benna S, O’Boyle C. Burn care experts and burn expertise. Burns 2014;40(2):200–3.
burns 40 (2014) 1232–1243
I.C.C. King* Registrar in Plastic and Reconstructive Surgery, Queen Victoria Hospital, East Grinstead RH19 3DZ, United Kingdom R. Vijayan SHO in Plastic and Reconstructive Surgery, Queen Victoria Hospital, East Grinstead RH19 3DZ, United Kingdom P.M. Gilbert B.S. Dheansa Consultants in Plastic and Reconstructive Surgery, Queen Victoria Hospital, East Grinstead RH19 3DZ, United Kingdom *Corresponding author. Tel.: +44 07816 877914 E-mail address: [email protected] (I.C.C. King)
Accepted 27 January 2014 http://dx.doi.org/10.1016/j.burns.2014.01.030 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
Letter to the Editor The paradigm of burn expertise: Scientia est lux lucis Dear Sir, The article entitled ‘‘Burn Care Experts and Burn Expertise.’’ has aroused the interest of King et al. [1]. I am ad idem with King et al. regarding certain of their considerations on ‘‘Burn Care Experts and Burn Expertise.’’ It is the obligation of health care professionals, such as King et al. to make careful, thoughtful appraisals [2–11]. Creating an environment where respectful and constructive controversy is healthy and stimulates the expression of different points of view is exactly the goal of King et al.’s well-functioning multidisciplinary team [12,13]. Experts are much more likely to reach an appropriate conclusion in a given situation than a novice. Experts have acquired extensive knowledge that affects what they notice and how they organize, represent, and interpret information in their environment. The 1568 text that defines the Renaissance is Giorgio Vasari’s ‘‘Lives of the Artist’’ [14]. In this text, Vasari articulates his view that expertise is attributed to talent [14]. It is sine qua non that expertise is correctly, but one-sidedly, associated with special abilities and enhanced performance [1]. Experts’ abilities to reason and solve problems depend on well-organized knowledge that affects what they notice and how they represent problems [1]. Experts are not simply ‘‘general problem solvers’’ who have learned a set of strategies that operate across all domains [1]. The fact that experts are more likely than novices to recognize meaningful patterns of information
1235
applies in all domains, including burn care [1]. Studies demonstrate that experts first seek to develop an understanding of problems and due to their ability to see patterns of meaningful information, experts begin problem solving at ‘‘a higher place’’ [1]. An emphasis on the patterns perceived by experts suggests that pattern recognition is an important strategy for helping students develop confidence and competence. These patterns provide triggering conditions for accessing knowledge that is relevant to a task. Nevertheless, even experts can ‘‘miss’’ and depending on the circumstance, this can be attributed to pre-existing bias that the novice does not have [1]. The other side of expertise, however, is surreptitiously hidden [1]. Along with expertise, performance may also be degraded, culminating in a lack of flexibility and error [15]. Expertise may be demystified by explaining the brain functions and cognitive architecture involved in being an expert [15,16]. These information processing mechanisms, the very making of expertise, involves an algorithmic quid pro quo that sometimes results in paradoxical functional degradation [1,15,16]. For example, being an expert entails using algorithms, selective attention, chunking information, automaticity and more reliance on top-down information, all of which allows experts to act rapidly and efficiently; conversely, these very mechanisms inhibit flexibility and control, may cause the experts to miss and ignore important information, introduce tunnel vision and bias and can cause other effects that degrade performance [15]. These phenomena are apparent in a wide range of expert domains, from musicians to air force pilots [16]. As Dr. King et al. opine, examining expertise in depth raises some interesting and complex questions. Experts neither have superior performance per se, nor are they exclusively superior or infallible. In fact, they are at times prone to specific types of degradations and errors. Expertise is not about being faster and more efficient, but rather that experts go about things differently [1]. This leads to improved performance in most cases, but not always [15,16]. Paradoxically, the very underpinning of expertise can entail degradation in performance as well, such as tunnel vision and biases. These are inherent algorithmic and cognitive trade-offs resulting from the brain functions of experts [15,16]. For example, as experts modify their mental representations, they form very efficient brain mechanisms, but these very mechanisms are inherently automatic and rigid, causing vulnerabilities that may result in degradation and error [17,18]. Recognizing and labeling an individual as an expert is to a large extent a social construct, often based on education, certification and social acceptance. These are not considered here, because the focus is on the actual expertise de facto. In other words, what are the brain and cognitive makings of an expert, rather than the external social issues involved (there may well be experts who are not socially recognized as experts, and conversely there may be recognized ‘‘experts’’ who in fact do not possess sufficient, or any expertise). ‘‘Burn Experts and Expertise’’ focused on what actually constitutes expertise, rather than the epistemological questions of how we recognize and know who an expert is [1]. As stated in ‘‘Burn Experts and Expertise’’, expertise is discussed and conceptualized in terms of expert
burns 40 (2014) 1232–1243
based on our prior studies [1]. As already stated pore sizes of these microfiber scaffolds are not a barrier to rapid cell infiltration as seen in this study. The authors also suggest that it will be necessary to orientate the skin pieces. We considered this initially but our pilot work showed no advantage in orienting these very small skin pieces in theses scaffolds. Unlike Meek grafts the skin will be finely minced and placed onto scaffolds and not placed directly onto a raw wound bed in vivo. Thus all skin pieces will be in contact with a large surface area of scaffold and we have in this preliminary study shown that skin cells are able to migrate along the fibres of the scaffold irrespective of their initial orientation and then reform a continuous epithelial barrier. Also in our recent study with limbal pieces we found the initial orientation of the tissue pieces did not influence the outcome. In summary while laboratory expansion of keratinocytes has a valuable role to play in helping surgeons restore a skin barrier for patients with extensive burns it will always be expensive and take time. Also epithelial cells alone do not solve the problem of how to replace the dermis and so far the challenges of a one-stage epidermal/dermal skin reconstruction remain tantalizingly close but not yet realized. In this preliminary study we suggest an approach for small-scale reconstructive surgery, which we think merits further investigation, and we thank the authors for their constructive comments.
Conflict of interest No conflicts of interest.
references
[1] Blackwood KA, McKean R, Canton I, Freeman CO, Franklin KL, Cole D, et al. Development of biodegradable electrospun scaffolds for dermal replacement. Biomaterials 2008;29(21):3091–104. [2] Glowacki JMS. Collagen scaffolds for tissue engineering. Biopolymers 2008;89(5):338–44. [3] Despande P, Sefat RC, Mariappan F, Johnson I, McKean C, Hannah R, et al. Simplifying corneal surface regeneration using a biodegradable synthetic membrane and limbal tissue explants. Biomaterials 2013;34:5088–106.
Kavita Sharma* Sheila MacNeil The Kroto Institute, University of Sheffield, North Campus, University of Sheffield, Broad Lane, Sheffield S3 7HQ United Kingdom *Corresponding author E-mail address: [email protected] (K. Sharma)
Letter to the Editor Comment on: Burn care experts and burn expertise Sir, We read this article with interest but feel compelled to address some of the points raised [1]. Expertise has to be measurable. If the concept of end-of-training examinations to enter onto a specialist register is not sufficient, consider the task a lawyer must face when qualifying a witness as an expert for the delivery of opinions in court. The concept of an expert must be definable and distinguishable from the role of a commentator. Whilst we agree that to some extent, expertise is a form of knowledge, the roles of education and experience are symbiotic rather than mutually exclusive. Indeed in surgical practice they nearly always go together, where expertise develops both theoretical and practical, applied knowledge. The suggestion that ‘‘experience obviates the need for conscious effort’’ [1] implies that experts molding treatment strategies in often complex burn cases do so with passive ease and little active thought. To state that ‘‘experts have an intuitive grasp of situations based on deep understanding and a repertoire of responses’’ [1] overlooks the use of evidence-based medicine in daily practice. Judgments, rather than becoming ‘‘effortless intuition’’[1], are made by experts based upon the evidence of best practice and whilst clinical scenarios may be familiar, one must distinguish between perception and that which is a wellinformed and balanced decision for the benefit of the individual patient. It is this continual appraisal of current practice with the growing evidence base that contributes to the development of expertise. The breadth of references within Al-Benna and O’Boyle’s paper – 33 of 36 were personal references – might reflect that the authors’ opinion differs from our own. Al-Benna and O’Boyle argue that burn care expertise is narrowed by sharing out the different phases of patient burn care between professionals, from resuscitation to rehabilitation [1]. We would suggest that, quite to the contrary, burn expertise is actually broadened by such measures, equipping professionals with the cumulative experience and in-depth understanding of current literature to deliver the optimum care available to patients throughout their burn treatment. The consideration that dividing burn care expertise results in less reliable judgments undermines the value of the well-established and valuable multidisciplinary structure of burn care. Yours faithfully,
Conflict of interest statement There are no conflicts of interest, financial or otherwise, associated with this work.
Accepted 21 January 2014
reference http://dx.doi.org/10.1016/j.burns.2014.01.016 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved. [1] Al-Benna S, O’Boyle C. Burn care experts and burn expertise. Burns 2014;40(2):200–3.
burns 40 (2014) 1232–1243
I.C.C. King* Registrar in Plastic and Reconstructive Surgery, Queen Victoria Hospital, East Grinstead RH19 3DZ, United Kingdom R. Vijayan SHO in Plastic and Reconstructive Surgery, Queen Victoria Hospital, East Grinstead RH19 3DZ, United Kingdom P.M. Gilbert B.S. Dheansa Consultants in Plastic and Reconstructive Surgery, Queen Victoria Hospital, East Grinstead RH19 3DZ, United Kingdom *Corresponding author. Tel.: +44 07816 877914 E-mail address: [email protected] (I.C.C. King)
Accepted 27 January 2014 http://dx.doi.org/10.1016/j.burns.2014.01.030 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
Letter to the Editor The paradigm of burn expertise: Scientia est lux lucis Dear Sir, The article entitled ‘‘Burn Care Experts and Burn Expertise.’’ has aroused the interest of King et al. [1]. I am ad idem with King et al. regarding certain of their considerations on ‘‘Burn Care Experts and Burn Expertise.’’ It is the obligation of health care professionals, such as King et al. to make careful, thoughtful appraisals [2–11]. Creating an environment where respectful and constructive controversy is healthy and stimulates the expression of different points of view is exactly the goal of King et al.’s well-functioning multidisciplinary team [12,13]. Experts are much more likely to reach an appropriate conclusion in a given situation than a novice. Experts have acquired extensive knowledge that affects what they notice and how they organize, represent, and interpret information in their environment. The 1568 text that defines the Renaissance is Giorgio Vasari’s ‘‘Lives of the Artist’’ [14]. In this text, Vasari articulates his view that expertise is attributed to talent [14]. It is sine qua non that expertise is correctly, but one-sidedly, associated with special abilities and enhanced performance [1]. Experts’ abilities to reason and solve problems depend on well-organized knowledge that affects what they notice and how they represent problems [1]. Experts are not simply ‘‘general problem solvers’’ who have learned a set of strategies that operate across all domains [1]. The fact that experts are more likely than novices to recognize meaningful patterns of information
1235
applies in all domains, including burn care [1]. Studies demonstrate that experts first seek to develop an understanding of problems and due to their ability to see patterns of meaningful information, experts begin problem solving at ‘‘a higher place’’ [1]. An emphasis on the patterns perceived by experts suggests that pattern recognition is an important strategy for helping students develop confidence and competence. These patterns provide triggering conditions for accessing knowledge that is relevant to a task. Nevertheless, even experts can ‘‘miss’’ and depending on the circumstance, this can be attributed to pre-existing bias that the novice does not have [1]. The other side of expertise, however, is surreptitiously hidden [1]. Along with expertise, performance may also be degraded, culminating in a lack of flexibility and error [15]. Expertise may be demystified by explaining the brain functions and cognitive architecture involved in being an expert [15,16]. These information processing mechanisms, the very making of expertise, involves an algorithmic quid pro quo that sometimes results in paradoxical functional degradation [1,15,16]. For example, being an expert entails using algorithms, selective attention, chunking information, automaticity and more reliance on top-down information, all of which allows experts to act rapidly and efficiently; conversely, these very mechanisms inhibit flexibility and control, may cause the experts to miss and ignore important information, introduce tunnel vision and bias and can cause other effects that degrade performance [15]. These phenomena are apparent in a wide range of expert domains, from musicians to air force pilots [16]. As Dr. King et al. opine, examining expertise in depth raises some interesting and complex questions. Experts neither have superior performance per se, nor are they exclusively superior or infallible. In fact, they are at times prone to specific types of degradations and errors. Expertise is not about being faster and more efficient, but rather that experts go about things differently [1]. This leads to improved performance in most cases, but not always [15,16]. Paradoxically, the very underpinning of expertise can entail degradation in performance as well, such as tunnel vision and biases. These are inherent algorithmic and cognitive trade-offs resulting from the brain functions of experts [15,16]. For example, as experts modify their mental representations, they form very efficient brain mechanisms, but these very mechanisms are inherently automatic and rigid, causing vulnerabilities that may result in degradation and error [17,18]. Recognizing and labeling an individual as an expert is to a large extent a social construct, often based on education, certification and social acceptance. These are not considered here, because the focus is on the actual expertise de facto. In other words, what are the brain and cognitive makings of an expert, rather than the external social issues involved (there may well be experts who are not socially recognized as experts, and conversely there may be recognized ‘‘experts’’ who in fact do not possess sufficient, or any expertise). ‘‘Burn Experts and Expertise’’ focused on what actually constitutes expertise, rather than the epistemological questions of how we recognize and know who an expert is [1]. As stated in ‘‘Burn Experts and Expertise’’, expertise is discussed and conceptualized in terms of expert
