This post is nod to my wife and the inlaws, who are big Arsenal FC fans…. What has Wenger got to do with medicine? Unfortunately I couldn’t find a tenuous link between Arsene and working in an ED, but Etienne Wenger does have a link.

Jean Lave and Etienne Wenger are cognitive anthropologists who developed the idea of communities of practice (CoP). “Communities of practice are groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly.” (Wenger 2007). For example, a group of school children trying to find their identity in school, a bunch of engineers working on similar problems, a group of surgeons working on novel surgical techniques or a group of EM consultants and nurses working on better ways to improve patient care in their ED…..

If you think about it, communities of practice are everywhere: at home; school; work; sports and hobbies. It’s about a process of collective learning by the participants over a period of time. The result is the development of practices which reflect the shared passion of the group. For example if you work in a Major Trauma Centre, how is the Code Red trauma response continually being developed and improved? Some CoP’s are formal and others more informal (a bunch of ED consultants chatting about how to improve sepsis management in their open plan office….) but the members are brought together by their common activities and what they’ve learnt from them.

Lave and Wenger described 3 elements of a CoP:

1) Domain: A domain of knowledge creates common ground and defines the CoP’s identity. Membership implies a commitment to the domain.

2) Community: As members share their interest in the domain through engaging in discussions and joint activities, they will learn from each other.

3) Practice: The members are practitioners. They develop shared ways of addressing new problems.

A famous example of a community of practice within an organization is that which developed around the Xerox customer service representatives who repaired the machines in the field (Brown & Duguid 2000). The Xerox reps began exchanging tips and tricks over informal meetings over breakfast or lunch and eventually Xerox saw the value of these interactions and created the Eureka project to allow these interactions to be shared across the global network of representatives. The Eureka database has been estimated to have saved the corporation $100 million. You see the chats about how to put the world to rights in the doctors’ mess or coffee room isn’t a waste of time!

Lave and Wenger looked into how apprenticeships worked. They described how newcomers to a community  would initially observe, then participate in basic activities and finally perform the more complex tasks. Now think about the afore mentioned Code Red trauma call or a paediatric cardiac arrest call or a complex multi trauma surgical case. There will be the “newcomers” ( e.g. medical/ nursing students) who stand at the back or at the periphery of the “community” just observing what happens. Eventually those same medical students will become junior doctors and participate in putting an intravenous cannula and taking bloods. Then, as they become more experienced, they will be the registrar putting in the chest drain or performing the intubation. Finally they will become the EM, paediatric or surgical consultant standing at the “centre” of the community, performing the most complex of procedures or leading the trauma call. Lave and Wenger described this process as “moving from legitimate peripheral participation to full participation.”

What CoPs exist in your own speciality? Are you at the stage of being a newcomer and a “legitimate peripheral participant” or are you the experienced member who is a “full participant”. I can think of many examples from my work, not least being a peripheral participant joining a big team as a new ED consultant observing how the department is run on a day to day basis. To be able to learn and improve practice ( i.e. have a successful CoP) the members must feel they are able to freely communicate their thoughts and opinions to each other. The members need to be motivated and have a strong collaborative ethos.

Once again, I hope this post has taught you something new. If you have read it, you are already a member of a very useful community……..#FOAMed!

KR

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