John Goldie is a retired GP and Medical Educator
In general practice, expertise is often tested not by clear-cut cases, but by the patient whose story defies guidelines and whose symptoms remain ambiguous. Here, the true mark of expertise is not certainty, but the capacity to sit with uncertainty and respond with thoughtful care.
Traditionally, expertise meant mastery — confident diagnoses and polished skills. Plato saw it as esoteric knowledge, guarded and exclusive. Yet sociologist Harry Collins reminds us secrecy is not inherent to expertise. Modern medicine reveals a more complex picture: expertise is not simply about accumulating facts or perfecting skills but about melding them. It requires balancing ‘knowing that’ — theoretical knowledge — with ‘knowing how’ — the embodied, practical knowledge and skills of patient care.1 Medicine is both art and science.
“… expertise is not simply about accumulating facts or perfecting skills but about melding them.”
Philosophers such as Wittgenstein and Winch remind us that actions cannot be understood without grasping the ideas behind them, and that ideas themselves are best understood in action. In clinical practice, this means evidence and skill are inseparable. The true expert applies robust research while also recognising and responding to the unique circumstances of each patient.
Experience alone does not equal expertise. Cognitive science shows clinicians shift between fast, intuitive reasoning (System 1) and slower, analytical thinking (System 2).2 Expertise means knowing when to trust instinct and when to question it. Pattern recognition helps but can mislead. Reflection, feedback, and humility are essential companions.3
This hybrid nature challenges reductionist views of intelligence. Michael Polanyi observed, ‘we can know more than we can tell’. Tacit knowledge — unspoken, embodied — is indispensable. Expertise is not a checklist but a choreography: knowledge, judgement, and care. Evidence-based practice (EBP) is part of this dance, but so are improvisation, ethical reflection, and adaptation. A 2019 review of EBP education stressed that embedding it requires dialogue, mentorship, and a culture of inquiry.4
In general practice, the label ‘expert’ can seem contradictory. The discipline is defined more by breadth than narrow specialisation. Yet within this breadth lies a unique expertise: managing uncertainty, integrating knowledge across domains, and keeping the patient’s story at the centre.
Formal frameworks help define expertise. The RCGP curriculum specifies capabilities assessed through exams and workplace-based assessments. The GMC’s Good Medical Practice reinforces lifelong learning, reflection, and ethics. These reassure patients and policymakers but cannot capture expertise’s full scope.
“A GP who excels academically but cannot connect with patients has not achieved expertise …”
Yet expertise is not only taught in classrooms; it is absorbed in corridors, clinics, and conversations — the hidden curriculum. Here trainees learn to balance compassion with pragmatism, and to navigate ethical dilemmas. The hidden curriculum can corrode empathy, but it is also the crucible in which resilience and professional identity are forged.
True expertise arises from the interplay of formal and hidden curricula. Knowledge and skills must be filled with wisdom, judgement, and relational depth. A GP who excels academically but cannot connect with patients has not achieved expertise. Just as empathy without knowledge risks safety, real expertise requires integration: competence with socialisation.
This duality brings tensions:
• Knowledge versus wisdom: guidelines offer evidence, patients present complexity.
• Assessment versus reality: portfolios show performance, informal feedback shapes confidence.
• Identity versus role: standards define ‘doctor’, culture shapes ‘colleague’.
These tensions are not flaws but vital to growth. They remind us expertise is dynamic, relational, and ethically nuanced. As general practice evolves with new roles and digital tools, adaptive expertise — the ability to transfer knowledge and innovate — becomes crucial.5 It develops not only in classrooms but in conversations, encounters, and private doubt.
“Expertise in general practice is a journey, not a destination.”
Not every trainee achieves expertise. Some plateau; others burn out. Difficulty tolerating uncertainty is a major contributor, especially early in careers.6 The differentiating factor often lies in metacognitive skills — reflecting on one’s own thinking — and the hidden curriculum of norms and role models. Expertise is dynamic, vulnerable to decay, and requires deliberate upkeep.7
In summary, expertise in general practice is a journey, not a destination. It begins with training, deepens with reflection, and matures through experience. The real test is not passing exams but sitting with patients in uncertainty, listening with compassion, and acting with integrity. In the end, expertise is less about mastery than about companionship in the unknown.
References
1. Cuevas‑Badallo A, Torres González O. Medical expertise as hybrid expertise: a proposal for the articulation of medical knowledge. Philosophy, Ethics, and Humanities in Medicine, 2025; 20(38).
2. Norman G, Pelaccia T, Wyer P, Sherbino J. Dual process models of clinical reasoning: the central role of knowledge in diagnostic expertise J Eval Clin Pract, 2024; 30(5): 788-796. DOI: 10.1111/jep.13998
3. Norman G, Eva K. Diagnostic error and clinical reasoning. Med Educ, 2010; 44(1): 94–100. DOI: 10.1111/j.1365-2923.2009.03507.x
4. Larsen CM, Terkelsen AS, Carlsen A-MF, Kristensen HK. Methods for teaching evidence-based practice: a scoping review. BMC Med Educ, 2019; 19(259).
5. Pusic MV, Hall E, Billings H, et al. Educating for adaptive expertise: case examples along the medical education continuum. Adv Health Sci Educ, 2022; 27(11): 1-18. DOI: 10.1007/s10459-022-10165-z
6. Peek R, Arnold R, Moore L. Greater tolerance of uncertainty facilitates thriving in doctors entering postgraduate training. BMC Med Educ, 2025; 25(1062).
7. Mylopoulos M, Regehr G. Cognitive metaphors of expertise and knowledge: prospects and limitations. Med Educ, 2007; 41(12): 1159_1165.
Featured photo by Clay Banks on Unsplash
