Re: tacit components of workplace learning for medical professionals

Tacit components of workplace learning for medical professionals

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Essay for the module of the ‘Education for the professionals’

Master of Arts in Clinical Education, Institute of Education, University of London

Module tutor: Dr. David Guile;

Essay supervisor: Prof. Ron Barnett

(4518 words)

Title

Tacit components of workplace learning for medical professionals: a limitation or possibility

Akira Naito, May. 2008

An ambiguity is not satisfying in itself, nor is it, considered as a device on its own,

a thing to be attempted; it must in each case arise from, and be justified by, the

peculiar requirements of the situation. On the other hand, it is a thing which the

more interesting and valuable situations are more likely to justify.

[William Empson, 1930]

… the critic who assumes that absolute values exist but that our knowledge of

them is always imperfect … he will conceive of art, like life, as being a self-

discipline rather than a self-expression. ... He will see artistic freedom and

personality as dependent upon the voluntary acceptance of limitations, which

alone are strong enough to test the genuine intensity of the original creative

impulse. [W. H. Auden, 1941]


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Abstract

Alongside providing specialised patient care, continuous development of their own expertise

is essential for medical professionals. The expertise to develop includes tacit components.

Such components may be gained through various activities such as continuous endeavours

of ‘reflections’ and positive and negative learning experiences, namely ‘trial-and-error’. This

process of development including tacit-learning is often depicted as “practice makes perfect”.

This process needs a capacity of experimentation with professional autonomy, but any error,

particularly a fatal one, could compromise professional standing.

In order to meet public expectation, an increased number of regulations concerning good

practice have emerged. Concurrently, socio-cultural development has advanced the public

demands from basic human necessities to higher needs, namely the ‘human rights’, which

would expect to consist more of tacit components. Medical professionals, therefore, have

come to face a dilemma that whether they should operate and tick-box/check-list purely on

the increasing number of explicitly defined standards.

This essay discusses the process of becoming a professional, operating within the regulations

and practical limitations. It reviews concepts relevant to tacit learning in the workplace using

Polanyi’s classification, and it argues that tacit process is manifested in the clinical workplace

and contributes to the development of expertise and identity.

(198 words)


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Introduction

Medicine, from or before the age of Hippocrates, has been developing its expertise, as one

of its goals, to discover and understand the nature of human beings, translating that

knowledge into practice so that symptoms can be defined (usually as diseases) and treated.

As one of the first vocations named as a profession, medicine has always been expected to

provide the professional service. Therefore, the individual practice of medicine is constantly

under scrutiny by the public.

Public expectation has been growing in accordance with concomitant socio-cultural and

technological development. The results of the socio-cultural development include the raised

level, in the Maslow’s hierarchy [Maslow, 1954], of the ‘human needs’, for example. That is,

from the level of a ‘necessity’ (basic needs: security and safety for existence) to that of a

‘right’ (higher needs: love, esteem and self-actualisation) [Carr, 1999]. In other words, the

nature of the needs has increasingly shifted weight towards its tacit (intangible and inferred)

components.

In order to meet the expectations, medical expertise needs continually to advance. This

process of advancement can be viewed in terms of a growing body of empirical evidence

about disease and its treatment, as well as the tangible implementations of this knowledge

which each patient encounters in clinical practice.


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The relationship between accumulating explicit evidence and its implementations is

reflected in the relationship between ‘theory’ and ‘practice’. Jonsen and Toulmin (1988)

indicated the theory as representing the ‘atemporal’ principles whilst the practice and its

goals of the profession are ‘temporal’ applications. The relationship between these

‘atemporal’ theories and ‘temporal’ practices are suggested to be inter-dependent [Jonsen

and Toulmin, 1988]. This inter-dependent relationship for medical professionals may be

described as follows.

The process of formulating scientific evidence consists of accumulating facts (as recorded

clinical and laboratory observations) and concomitantly extracting theoretical principles

from these. These theories, then, act as ‘atemporal’ academic frameworks to aid the

interpretation and prediction of such ‘temporal’ observations. This process is also linked to

each professional’s experience and how they apply this to his/her practice. In this way,

clinical practice becomes an additional source of evidence.

The accumulated individual experience of medical professionals in these circular processes

has advanced the scientific knowledge-base and improved the quality of clinical practice of

the medical profession as a whole. Knowledge, particularly knowledge gained from

experience, has both tacit (intangible and embodied) and explicit (defined) components.

These components can also be seen continuously to interact and influence each other in the

circular loop between ‘theory’ and ‘practice’.


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Tacit components in the workplace for medical professionals

In the process of developing professional expertise (knowledge and action) in the workplace,

tacit components may play an important role since the cyclical loop is continuous and open-

ended:

… the connections between knowledge and action have an infinite open-endedness

about them. ... There is an epistemological gap … a praxis gap … And there is an

ontological gap, since the presenting situation does not totally structure the

professional identity - the professional being - that is to be offered to the world.

[Barnett, 1997, p. 140]

As Barnett suggested, the development of professional expertise includes not only obtaining

specialised knowledge and actions, but also attaining the ‘professional identity’. The

‘identity’ of professional beings includes their inner morality as well as their professional

identification which act as an outlook (or the ‘structure’ in Barnett’s notion) to offer to the

public.

Alongside the socio-cultural development, a growing number of detailed regulations have

enacted for individual professionals in their clinical practices. These regulations include

practical guidelines for their professional development [Modernising-Medical-Careers, 2007],

and for their clinical decision-making and procedures (with theoretical algorithms as their


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heuristic knowledge-base in some cases), which each professional ‘should’ follow. In other

words, increasing explicit (defined) rules and manners for the medical professionals at their

workplace have emerged and have been specified.

Although the increase in explicit rules and standards of practice can have clear benefits by

helping to ensure adequate and up-to-date professional care, it may also be viewed as an

increase in the level of external control, and come with additional costs. That is, such

changes may have extreme consequences regarding the professional identity, which

comprises individual inner-self and his/her personal view of the profession, specifically:

(1) A decreased sense of autonomy as a consequence of the increased ‘external control’

may contribute to the risk of damage to a professional’s inner impetus, unprompted

intention or ‘will [Barnett, 2007]’ to act as a professional-self; and

(2) An overwhelming sense of obligation as a consequence of the increased number of

regulations may reduce the individual’s motivation [Maslow, 1954] or emotion-

associated drives and their ability to appreciate their own view of professional

identity as well as their desire to provide better service.

Becoming a medical professional

The inquiry into these potential extreme risks can be paraphrased as a query: whether

medicine should become a service mostly (or completely) dictated by detailed expected


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outcomes, or if there can or should be some limits placed on the explicit standards in order

to avoid the risks and to protect individual professionalism.

If the practice of medicine is to be dictated mostly or primarily by externally-set standards,

the medical professionals may no longer need to have autonomy; that is, medical

professionals may no longer need, ironically, their professional identity. In this case,

however, the crucial question arises as to who should ‘act’ as the public? In other words,

who is responsible and capable in the real world to examine and to define the ideal

regulations and standards?

Practically, regulations must be enacted with considerations of the feasibility in the light of

limitations of potential resources, with regard to the number of people, material, equipment,

finance, space and place for instance. This feasibility can be examined after or during the

actual implementation of such regulation in each clinical practice. Therefore, it should,

theoretically and practically, be the professionals themselves who are involved in the actual

processes of developing such standards of care in order to realise their practical and

accountable service.

Medical professionals may, therefore, be expected to carry out dual roles (to formulate

atemporal rules and to be assessed by the rules in each temporal condition), specifically as:

(1) Individuals who are responsible for generating and examining the regulations; and


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(2) Individuals who are evaluated and examined in the light of the regulations.

These roles can be taken by different individuals in turn within the whole professional body

or in different time and occasions in the local professional community. The activities to take

these roles can contribute to formulate and develop the professional identity (and

autonomy) not only for individual professionals but also as a whole profession.

The process of becoming a professional being involves that of seeking and formulating self-

identity as well as realising the dual roles outlined above. In this process, implementation of

the notion of professional-identity (identification) into the self-identity emerges, and this

process involves cyclical endeavours similar to these between ‘theory’ and ‘practice’

described above.

The cyclical process of individual professionals for tacit learning to improve medical

expertise and to develop identity implies that there is an area of capacity with which the

process of learning and development takes place. Polanyi identified “three areas where tacit

process co-operate with explicit” [Polanyi, 1958]:

1) Domain of implicitness: the area where the tacit component is inferred implicitly

but undefined so that the tacit is co-extensive with explicit information and carries

meaning which may or may not become explicit in due course;

2) Domain of sophistication: the area, in which the tacit and the formal are apart,

comprise two extreme facets: (a) incompetence of speech because poor articulation


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hinders the tacit work of thought; and (b) symbolic operations which outrun but

follow some operational rules without carrying meaning even in the inappropriate

context; and

3) Domain of ineffability: the area where the tacit predominates to the extent that

articulation is virtually impossible.

Domains of ‘implicitness’ in the tacit components

The domain of ‘implicitness’ is labelled ‘clinical uncertainty’ in medicine [Hall, 2002]. This

uncertainty (ambiguity or complexity) is the area where the clinician depends on

‘intelligence’ or ‘trial-and-error’ experience to determine the choice of action when he/she

consciously (but ‘arbitrary’) tries to avoid operating/practising according to his/her habit:

Claparède opposes intelligence to instinct and habit … it begins with the most

elementary empirical trial-and-error. … For K. Bühler, … intelligence only appears with

acts of insight (Aha-Erlebnis) while trial-and-error is a form of training. … We must

therefore choose between these two alternatives: either we must be satisfied with a

functional definition at the risk of encompassing almost the entire range of cognitive

structures, or else we must choose a particular structure as our criterion, but the choice

remains arbitrary and runs the risk of overlooking the continuity which exists in reality.

[Piaget, 1950, p. 10-11]


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The notion of ‘intelligence’ in this Piaget’s discourse may overlap with the Hegelian notion of

a ‘dialectic triad’. That is, the triad between thesis, anti-thesis and synthesis. These ‘dialectic

triads’ and ‘trial-and-error’ experiences share the process of ‘experimentation’ in which one

should have an (undefined but arbitrary) exploratory challenge with attitude of ‘not-

knowing’ about outcomes beforehand. This arbitrary challenge can then result in an explicit

outcome, and therefore, may (or may not) be clarified in due course. This type of experiment

can be purely psychological (in the process of anti-thesis, for example) or it may involve

some physical bodily components. For the purpose of clarifying the ‘implicitness’ and

obtaining the expertise belong to this domain of the tacit components, it can be summarised

that the ‘dialectic triad’ and/or ‘trial-and-error’ experiences may be consciously but arbitrary

(or unconsciously) applied as a methodology/strategy.

Domains of ‘sophistication’ in the tacit components

The second area, the domain of ‘sophistication’, may occasionally be raised to the level of

consciousness in an unpredictable manner, with surprise, so that it becomes explicit and can

be articulated and stipulated accordingly. Schön depicted this process of formularisation or

sophistication of explicit knowledge from tacit components as the expression of ‘reflection’

[Schön, 1983], particularly the ‘reflection-in-action’ which occurs simultaneously with an

action and ‘reflection-on-action’ which takes place subsequently:

Much reflection-in-action hinges on the experience of surprise. When intuitive,

spontaneous performance yields nothing more than the results expected for it, then we


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tend not to think about it. But when intuitive performance leads to surprises, pleasing

and promising or unwanted, we may respond by reflecting-in-action. … In such processes,

reflection tends to focus interactively on the outcomes of action, the action itself, and

the intuitive knowing implicit in the action. [Schön, 1983, p. 56]

In this context, the ‘intuitive’ (re)action/knowing would also be conceived and labelled as an

improvisation, and therefore, objects identified as part of the reflective process (‘reflection-

in-action’ in particular) include outcomes of the results from improvisations in the form of

momentary ‘trial-and-error’ experiences. Hence, the domains of ‘implicitness’ and

‘sophistication’ may overlap with each other in ‘trial-and-error’ experience. The main

difference, however, is that the process of clarification, when the transition from the tacit to

the explicit component occurs, in the domain of ‘sophistication’ has an element of ‘surprise’.

In other words, an individual in the process of learning the domain of ‘sophistication’ had no

anticipation (or pre-cognition/plan) to have an ‘experiment’ before when he/she happens to

experience the (surprising) learning event. He/she may then realise that the experience was

an experiment afterwards, so that he/she can attain its sophistication by retrospective

reflections.

This domain of ‘sophistication’ may, therefore, be classified as the level of development

where careful reflections of what one did not anticipate, or even did not know the existence

of, learning but experienced as part of the event. In this case, theoretically, the same

knowledge can be anticipated by more experienced practitioners. In other words, the area


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may be tacit to the novice learner but it can be recognised and guided by the expert. In the

context of the development of mind, Vygotsky theorised that such an area related to a ‘zone

of proximal development (ZPD)’:

It is the distance between the actual development level determined by independent

problem solving and the level of potential development as determined through problem

solving under adult guidance or in collaboration with more able peers. … The zone of

proximal development defines those functions that have not yet matured but are in the

process of maturation, functions that will mature tomorrow but are currently in an

embryonic state. [Vygotsky and Cole, 1978, p. 86]

Or more specifically, their strategy for the ‘guidance’ is explained as in the notion of the

‘scaffolding’ in the ‘zone of proximal development’:

This “scaffolding” interpretation has inspired pedagogical approaches that explicitly

provide support for the initial performance of tasks to be later performed without

assistance. [ibid., p. 48]

Hence, the notion of the ‘sophistication’ may also be labelled as maturation, suggesting the

possibility that this area of tacit components can be guided to develop. Collectively, the

‘reflections’ experienced and/or the ‘guidance/scaffolding’ given by more experienced

individuals may be a useful method/strategy of exploring the domain of ‘sophistication’.


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Domain of ‘Ineffability’ in the tacit components

The last part of the tacit components categorised above, the domain of ‘ineffability’, may

never be explicitly recognised but might be passed on from a predecessor to a descendant in

the form of an apprenticeship. This tacit learning process was suggested to occur naturally

via ‘observation, assimilation and emulation’ which happens over time without receiving any

intentional interventions from more experienced others [Guile and Young, 1998]. This

process involves ‘trials-and-errors’ experience and some ‘reflective’ activities. Thus, the

learning should involve the domains of ‘implicitness’ and ‘sophistication’ as well as explicit

components. The adage of “practice makes perfect” (this notion can be traced back to the

1550s as in Latin form of the “Usus promptos facit”) may portray this process as a whole.

Although the explicit learning objectives of ‘ineffability’ cannot be recognised, the value and

purpose may be shared by the learner and his/her master. In other words, the target of the

learning process itself need not be articulated but can be found in the outcome of the

actions as a product. An example of this kind of goal can be seen in the pursuit of artistic

mastery. Similarly, this course of actions was also characteristically introduced as an eastern

concept of ‘cultivation’ [Yuasa and Kasulis, 1987], and the shared aim in this pursuit was the

notion of ‘true knowledge’ which inevitably has a tacit nature:

True knowledge cannot be obtained simply by means of theoretical thinking, but only

through “bodily recognition or realisation (tainin or taitoku)”, that is, through the

utilization of one’s total mind and body. … Cultivation is a practice that attempts, so to


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speak, to achieve true knowledge by means of one’s total mind and body. [Yuasa and

Kasulis, 1987, p. 26]

Yuasa further argued a type of inner development of self-realisation by ‘cultivation’,

particularly in the development of traditional artistic mastery, using an analysis of the

relationship between, and the integration of, ‘mind and body’:

… Art is embodied through cumulative training; one comes to learn an art through

training or disciplining means to make the mind’s movements accord with the body’s. …

Initially, the body’s movements do not follow the dictates of the mind. The body is heavy,

resistant to the mind’s movement. … the mind (or consciousness) and the body exhibit an

ambiguous subjective-objective dichotomy within the self’s mode of being. To harmonize

the mind and body through training is to eliminate this ambiguity in practice. … This is a

practical, not a conceptual, understanding. [ibid., p. 105]

The notion of a united ‘mind and body’ includes ‘intuitiveness’, since intuition is used to

describe when there is no separation of time between thinking and ‘knowing’ or ‘acting’.

This would suggest that no analytical process occurs between the event of knowing, which

refers to a psychological response in the mind including emotion, and acting, which refers to

a physiological response to the stimulus.


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Time is an important factor to take into account for workplace learning and developing tacit

components in this bodily sense. If the time for the development of expertise is to be

manifested in a short period, its appearance is often judged or assumed to be an intuitive

operation both by the performer him/herself and by others [Eraut, 1994]. Eraut suggested

that the development of expertise can also mean the shifting from the deliberative mode of

thought and action to the intuitive mode. That is, the development of expertise comprises

the learning of the tacit components. Eraut’s suggestion also implies that a sufficient amount

of time is needed to achieve this.

In summary, the endeavours of ‘cultivation’ and/or repeated actions of ‘observation,

assimilation and emulation’ for the purpose of achieving explicitly recognised mastery have

also a possibility to develop and to educate the domain of ‘ineffability’ and the ‘intuitiveness’.

The outlook of these tacit learning components, which includes developing the embodied

knowledge or tacit expertise in particular, was also analysed and described from a socio-

cultural perspective. On this view, the learning is an integral and inseparable aspect of ‘social

practice [Lave and Wenger, 1991]’, so that all the three domains (implicitness, sophistication,

and ineffability) can be viewed as a whole and without clear separation even from the

explicit components. Moreover, the society where the learning can be observed as a whole

is labelled as the ‘communities of practice’:

We interact with each other and with the world and we tune our relations with each

other and with the world accordingly. In other word, we learn. Over time, this collective


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learning results in practices that reflect both the pursuit of our enterprises and the

attendant social relations. These practices are thus the property of a kind of community

created over time by the sustained pursuit of a shared enterprise. It makes sense,

therefore, to call these kinds of communities ‘communities of practice’. [Wenger, 1998, p.

45]

The methodologies summarised above can also be viewed as a whole within a socio-cultural

perspective, and may be interpreted as within a type of ‘participation’ in their definition:

Participation is always based on situated negotiation and renegotiation of meaning in

the world. This implies that understanding and experience are in constant interaction -

indeed, are mutually constitutive. The notion of participation thus dissolves dichotomies

between cerebral and embodied activity, between contemplation and involvement,

between abstraction and experience. [Lave and Wenger, 1991, p. 51-52]

Hence, the notion of the ‘participation’ may be considered as a method of approaching the

tacit components as a whole rather than in one of the three domains. Although these three

domains may overlap with each other, the main approaches suggested above can be

summarised according to each domain in Polanyi’s classification [Table 1].


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Table 1: a summary of different tacit learning (the categories of ‘domains’ employ the Polanyi’s three domains [Polanyi, 1958])

Domains Aims Main learning methods in each domain

Implicitness Clarification of

the clinical uncertainty

‘trial-and-error’ [Piaget, 1950]

‘dialectic-triad’ aiming to lead ‘synthesis’

Sophistication Maturation of ZPD [Vygotsky

and Cole, 1978]

‘reflection’ [Schön, 1983]

‘guidance/scaffolding’ by experienced practitioners

Ineffability Self-realisation of intuitiveness in bodily sense

‘observations, assimilations and emulations’

‘cultivation’ [Yuasa and Kasulis, 1987]

Across three ‘domains’

Socio-cultural development

‘practice makes perfect’

‘participation’ in the ‘communities of practice’ [Lave and Wenger, 1991]

Tacit nature of identity as a professional individual and as a whole profession

The aim of workplace learning for medical professionals is for them to attain better patient-

care management and safety. This can be summarised as the requirement to develop both

professional expertise and identity. In the process of this development, tacit components are

pervasive as discussed above. However, there are a number of limitations that need to be

taken into account with regard to learning these tacit components. For instance, although

some of tacit learning can result in explicit outcomes in due course as discussed above, the

tacit learning itself cannot be guided or monitored step by step, so that the result of such

learning will only be indirectly and unconsciously realised or integrated with other learning


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outcomes. Even if an associated manifestation of tacit learning can be achieved, it would

also be perceived as a surprise for each individual. That is, the exact time and course of the

learning itself will never be articulated.

The Dreyfus brothers proposed one perspective, which allows for the level of the expertise a

learner has obtained to be viewed, as the individual learner’s stage of development. For

example, Level 1 may represent a novice, level 2 an advanced beginner, level 3 a competent

individual, level 4 proficient, and 5 an expert [Dreyfus et al., 1986]. This was presented in the

context of ‘skill acquisition’, but as Eraut pointed out in his description of Dreyfus’ model (p.

124-125) [Eraut, 1994], the emphasis is more on perception than observation of acquiring

specific explicit skills. The more advanced the level, the more process can be delivered in a

semi-automated fashion. That is, decision-making activities appear to become increasingly

tacit as the level increase. This importance of, and focus on, involvement of tacit

components for the model of an expert’s attributes was typically explained in the contrast

between machine and human being:

Despite the “rationalization” of work and its decomposition into precisely specifiable

motions … human beings never attain the precision of rule-following machines. Human

beings, however, exhibit a flexibility, judgement, and intuition that resist decomposition

into specification and inference and have proved equally difficult to instil into logic

machines. [Dreyfus et al., 1986, p. 63]


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Hence, although individual (separate) tacit components at a certain time and place may

never be specified and articulated in order to be monitored, there is a possibility that the

outcomes may be able to come into view as the level of individual development progresses

so as to result in the experience of individual ‘flexibility, judgement, and intuition’.

An alternative perspective to be able to tackle these dilemmas and limitations is the view

from the socio-cultural constructivism standpoint. Such an approach allows the expertise of

the individual (and identity) to be considered as a ‘social attribute’ rather than an ‘individual’

one (driven from the view of the atomism/reductionism standpoint such as Piaget’s) [Guile

and Young, 1998; Swanwick, 2005]. In this perspective, there is the possibility that strategies

can be used to monitor the development of the expertise and identity so that strategies to

guide and facilitate the development may also be planned and implemented. This can be

done, in theory, by emphasising the target objectives based on the overall outcome as a

whole which relates to the notion of ‘communities of practice’, and individual attributes may

be more focused on associations to the overall outcomes as represented in the notion of

‘participation’ for the purpose of ‘becoming’ a part of the community [Lave and Wenger,

1991] as introduced above.

To investigate the ways in which the medical practice as a whole professional ‘communities

of practice’ (profession) might be evaluated is another challenging query. For this inquiry,

Bruner’s proposed analysis regarding perspectives of culture may be useful. He argued that

members of communities create and share the meaning of their activities in each situation,


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namely “meaning-making” activities implemented in the light of the “definition of the

situation”, that is, in each ‘here and now’ occasion. All members can be seen as taking part in

formulating the culture of the community in turn. Bruner labelled these activities

“transactional turn”:

As members of our species, we live in that network as well as in nature. We form our

allegiances and construct our communities around this sharing. … “meaning-making” …

The second perspective on the cultural in evolution is more collectivist, and emphasizes a

“transactional turn” as crucial to the human way of life. … So, in the end, while mind

creates culture, culture also creates mind. … Biology and culture both operate locally;

however grand the sweep of their principles, they find a final common path in the ‘here

and now’: in the immediate “definition of the situation”. [Bruner, 1996, p. 164-167]

Hence, it may be summarised that each member of the ‘community’ may have more than

two roles as a professional, and play a part of the ‘meaning-making’ activities within the

community by taking ‘transactional turns.’ In this claim, these activities can be viewed and

evaluated as a whole ‘community’ or as an individual sub-group of the ‘communities’ on the

basis of the “definition of the situation.”


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Summary and conclusions

This essay reviewed the concepts regarding tacit knowledge relevant to workplace learning

for medical professionals, with an attempt to summarise the strategies for tacit learning

[Table 1]. In short, activities (consciously or unconsciously) occurring in the workplace, such

as the ‘trial-and-error’ endeavours, ‘dialectic-triad’ exercises, ‘reflections’, ‘cultivations’

and/or ‘participations’, may be considered as a useful methodology for individual

professionals to develop tacit components of the medical expertise and professional identity.

It is also highlighted that these methodologies have to be applied in the light of the

“definition of the situation” in order to fit in purpose for each specific occasion and situation.

This essay suggested the possibility that the potential conflict, between two opposed but

interdependent notions, may generate the next step for the development of tacit learning.

The need arises to find a balance, whenever and wherever two dichotomised concepts

emerged. Or it may be that a shift in focus is needed, moving from articulation of detailed

individual attributes to evaluating more end results (outcomes) of the whole project as well

as of individual detailed objectives. Hence, it is summarised that the outcomes, which may

be retrospective and ambiguous (not-articulate) but can be applied and used in order to

evaluate the tacit learning, include:

(1) the level of association to a specific project/purpose when the project/purpose was

completed; and

(2) a stage of professional development (as an individual being and as a whole profession).


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There still remains an unaddressed issue regarding workplace learning for medical

professionals. That is, whether the current increase in the number of regulations, which

must be enacted with inevitable considerations of the feasibility, could be an obstacle for

the medical professionals in terms of tacit learning. In order to address the balance between

regulations and autonomy, the size of the ‘communities of practice’ should be considered.

The size would need to be equivalent for the whole community under the regulation (nation

wide, for example) as well as for each community to find a balance and a suitable

methodology for their tacit learning in each occasions. The larger the size becomes, the

more the complexities and variations that could appear, which in turn could represent a

limitation. Whether this complexity can be viewed as a limitation or possibility may depend

again upon the “definition of the situation” as Empson (1930) and Auden (1941), respectively,

suggested in their discourses:

… it must in each case arise from, and be justified by, the peculiar requirements of the

situation. On the other hand, it is a thing which the more interesting and valuable situations

are more likely to justify.

… artistic freedom and personality dependent upon the voluntary acceptance of limitations,

which alone are strong enough to test the genuine intensity of the original creative impulse.


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NB. - Supplemental quotes -

[Jonsen and Toulmin, 1988]:

Medicine blends theory and practice, intellectual grasp and technical skill, episteme and phronesis, in its own characteristic manner. … In doing so it illustrates the complex and subtle ways in which theoretical and practical knowledge bear on each other. (p. 37)

[Eraut, 1994]:

Speed of thoughts and action emerges as a critical variable when considering the nature of expertise. … a major problem for all professionals is making sufficient time to engage in deliberative as well as rapid and intuitive modes of thought and action. (p. 23)

[Carr, 1999]:

It is significant that the kind of services that professionals are in business to provide have increasingly come to be regarded as human ‘rights’; thus, human rights to life, liberty and freedom of thought and association, so many of the services now under the control and direction of the more or less established traditional professions – healthcare, legal aid, education and so on – are apt to be characterised as ‘welfare’ rights. (p. 37)

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Re: tacit components of workplace learning for medical professionals