What happens when we don’t use the wisdom we have spent decades building?

Why can an experienced clinician sometimes cut through extraordinary clinical complexity in seconds, yet find learning a new digital system overwhelmingly difficult?

Towards the end of my clinical career, I became increasingly aware of this apparent contradiction.

Sometimes I could recognise Parkinsonism almost before I could consciously articulate what I had seen. A particular movement. A posture. The way someone walked into the room.

I wasn’t thinking faster. I was recognising.

Yet put a new electronic patient record in front of me and, at times, it could feel overwhelmingly difficult.

The explanation may lie in something psychologists have understood for decades: our cognitive strengths change as our careers evolve.

And that raises an important question for healthcare organisations.

Are we making the best use of the strengths our most experienced clinicians have spent decades developing?

From fluid to crystallised intelligence

Psychologist Raymond Cattell first distinguished between two forms of intelligence, later developed further by John Horn.

Fluid intelligence describes our capacity to reason rapidly, manipulate information in working memory, recognise novel patterns and solve unfamiliar problems. It underpins cognitive flexibility and our ability to learn quickly.

Crystallised intelligence is different. It represents the accumulated knowledge, judgement, expertise and pattern recognition built through experience.

It is knowing not simply what to do, but when to act, when not to act, and how to interpret complexity.

Arthur Brooks popularised this distinction in From Strength to Strength, arguing that later career should not simply be understood as a period of cognitive decline. Rather, the nature of our cognitive strengths changes.

There is neuroscience underpinning this.

Fluid intelligence draws on distributed brain networks, particularly involving frontal and parietal regions that support working memory, attentional control and complex problem solving. Across adulthood, changes in processing speed and in the structure and connectivity of these networks are associated with declining performance on some fluid intelligence tasks.

Crystallised intelligence draws more heavily on accumulated semantic knowledge and learned associations. Unlike many fluid abilities, it is generally maintained for longer across adulthood and may continue to increase well into later life.

The result is important.

Experienced clinicians may sometimes process novel information less rapidly, while simultaneously becoming extraordinarily good at recognising familiar patterns, understanding context and exercising judgement.

We see this throughout medicine.

A younger clinician may assimilate a new protocol remarkably quickly. An experienced clinician may look at a patient and recognise that, on this occasion, the protocol doesn’t quite fit.

That isn’t simply knowledge.

It is knowledge compounded by experience.

But what happens to that expertise?

This is where neuroscience collides with something apparently much more prosaic: how we structure clinicians’ work.

Direct clinical work is relatively easy to see and measure.

Clinics can be counted. Theatre lists can be counted. Procedures can be counted. Waiting list activity can be counted.

Non clinical programmed activities (PAs) are different.

Teaching. Mentoring. Supervision. Research. Quality improvement. Service redesign. Leadership. Coaching. Writing guidance. Developing future leaders.

Their value often emerges over months or years and may never appear neatly on a performance dashboard.

Under intense financial and operational pressure, it is entirely understandable that organisations focus on what they can measure.

But there may be an unintended consequence.

At exactly the point in a clinician’s career when their accumulated experience is greatest, we may increasingly ask them to concentrate on the activities that are easiest to count.

When the measure becomes the target

This brings us to Goodhart’s Law.

Economist Charles Goodhart observed that when a measure becomes a target, it ceases to be a good measure.

Measures help us understand performance. But once a particular measure becomes the dominant target, behaviour inevitably adapts around it.

Healthcare is full of things we need to measure: waiting times, productivity, training completion, financial performance and compliance.

The problem comes when what we can measure gradually becomes confused with what we value.

Direct clinical work is visible.

Much of the contribution made through non clinical PAs isn’t.

If measurement increasingly determines perceived value, organisations will naturally protect the former while scrutinising the latter.

Not because teaching, mentoring, leadership or improvement lack value.

Because their value is harder to count.

Today’s activity and tomorrow’s capability

There is another useful distinction from organisational science: productive efficiency and adaptive capacity.

Productive efficiency asks:

How can we maximise today’s output using the resources we have?

Adaptive capacity asks:

How well are we learning, improving and preparing ourselves for tomorrow?

Healthcare organisations need both.

Direct clinical work contributes directly to productive efficiency. It delivers healthcare today.

Non clinical PAs can contribute disproportionately to adaptive capacity: teaching, mentoring and supervising colleagues; improving systems; supporting innovation; building culture; and developing the next generation of clinical leaders.

The difficulty is that the first is much easier to measure than the second.

Under pressure, that creates a powerful incentive to move clinicians’ time towards immediate, measurable activity.

But doing so may simultaneously reduce the organisation’s capacity to learn, improve and develop.

Turning experience into organisational capability

This leads to a different way of thinking about non clinical PAs.

Perhaps they should not primarily be viewed as time away from clinical activity.

Perhaps they are one of the mechanisms through which an organisation converts individual crystallised intelligence into organisational capability.

An experienced clinician’s judgement has value when they personally make a good decision.

But its value multiplies when they teach someone else how to make that decision.

It multiplies again when they mentor a colleague, redesign a failing service, improve a pathway, supervise the next generation, coach a future leader or help create a culture in which other people can do their best work.

Crystallised intelligence accumulates within individuals.

Its greater organisational value may come from creating opportunities for that experience to be shared, transferred and built upon by others.

That distinction matters.

Because once we view these activities simply as time away from direct clinical work, the obvious response under pressure is to reduce them.

If instead we view them as mechanisms for capturing, transferring and compounding expertise, the calculation becomes rather different.

And perhaps this matters for retention

Experienced clinicians rarely stop wanting to contribute.

But they may increasingly want to contribute differently.

As careers progress, many clinicians become increasingly interested in teaching, mentoring, improving systems, developing colleagues and shaping the environments in which care is delivered.

This may not represent disengagement from clinical medicine.

It may be the natural evolution of expertise.

If the only contribution an organisation appears to value is more measurable clinical activity, we risk making employment less attractive at precisely the stage when clinicians have accumulated the greatest experience.

Perhaps that helps explain an apparent paradox: some clinicians retire from substantive NHS roles and then continue enthusiastically teaching, mentoring, writing, coaching or contributing to professional organisations.

They haven’t stopped wanting to contribute.

They have changed how they want to contribute.

What do we choose to value?

None of this is an argument against direct clinical work.

Patients need clinics. Operations need to happen. Waiting lists matter. Productivity matters.

Nor is every non clinical PA necessarily valuable simply because its impact is difficult to measure.

The challenge is more interesting than that.

It is about recognising that measurability and value are not the same thing.

Healthcare organisations face extraordinary immediate pressures. It is rational to focus on today’s activity.

But the organisations that thrive over the longer term will also need to preserve their ability to learn, adapt and develop people.

And that means finding ways to use the changing strengths of clinicians across the whole of their careers.

Perhaps consultant job planning should therefore be understood not simply as an exercise in allocating sessions, but as a strategic decision about how we deploy human capability.

The question may not be how many non clinical PAs an organisation can afford.

It may be how much accumulated wisdom it can afford not to use.

Dr Paul Molyneux is a consultant neurologist, former NHS medical director and co-founder of The Thriving Life Consultancy