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

Letter to the Editor

Comment on: Burn care experts andburn 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

b u r n s 4 0 ( 2 0 1 4 ) 1 2 3 2 – 1 2 4 31234

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.

r e f e r e n c e s

[1] Blackwood KA, McKean R, Canton I, Freeman CO, FranklinKL, Cole D, et al. Development of biodegradable electrospunscaffolds for dermal replacement. Biomaterials2008;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 regenerationusing a biodegradable synthetic membrane and limbaltissue 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: misskssharma@gmail.com (K. Sharma)

Accepted 21 January 2014

http://dx.doi.org/10.1016/j.burns.2014.01.016

0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.

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 well-

informed 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 profes-

sionals with the cumulative experience and in-depth under-

standing 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-estab-

lished 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.

r e f e r e n c e

[1] Al-Benna S, O’Boyle C. Burn care experts and burn expertise.Burns 2014;40(2):200–3.

b u r n s 4 0 ( 2 0 1 4 ) 1 2 3 2 – 1 2 4 3 1235

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: ianccking@doctors.org.uk (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 multi-

disciplinary 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 knowl-

edge 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

applies in all domains, including burn care [1]. Studies

demonstrate that experts first seek to develop an under-

standing 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 com-

petence. 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 func-

tions 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 algo-

rithms, selective attention, chunking information, automati-

city 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 under-

pinning 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 representa-

tions, 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 episte-

mological 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