Sitting next to the middle fork of the Gila River in the wilderness of New Mexico is where I got one of my most salient lessons on the stages of learning. The prototype of the exercise was how well you could do a cartwheel. My first thought was “When the hell was the last time I did a cartwheel?” Sadly, I had no idea. As I reviewed memories of cartwheels sprinkled through my childhood, the question arose, “Does my memory of how good I was even count for how good I am today?” I decided there was only one answer and no excuses, I would have to do a cartwheel. After a deep breath and my feet returning to the ground, I can report no injuries were sustained and I believe I am a “competent” cartwheeler. My fellow self-identified “competent cartwheeling” colleagues and I were then tasked to discuss why we were competent. After some discussion and group sharing, the next question probed further, “How might we get better? How might we become ‘proficient’?”
As learners, we learn in steps. We slowly add facts and skills together until we can weave them into more complicated processes and pathways. For a cartwheel, this means linking multiple motor skills in a stepwise fashion. In medicine, this means transitioning our basic science knowledge and physical exam skills into clinical decision making. As teachers, we must be cognizant of what stage our learner is at. As the saying goes, it is pointless to teach someone to cartwheel before we teach them to walk (or something like that). Before we teach anything, we have to assess our learner and determine the appropriate lesson for them.
Fortunately for us, a variety of theories and models of the stages of learning have already been developed. As I researched this topic, going from one reference to the next, I realized the border between stages of learning and theories on how we learn is quite blurry. There are many references at the end if you would like to follow my path down the rabbit hole, but today, I am going to use the Dreyfus model of stages of learning as my framework. The Dreyfus model was actually developed by two brothers who were engineers. The model focuses on how we acquire technical skills. It has been studied and adapted for the medical field, most notable by Patricia Benner in nursing education. Like all good models, it has its strengths and weaknesses, but I think it serves as a strong foundation to layer on other theories and one’s own experience.
Dreyfus Five Stages of Learning
1. Novice – You don’t know what you don’t know
The novice doesn’t know anything except what you teach them. They work strictly from the rules they are taught and don’t understand the broader context into which they fit. They will take things literally with no ability to improvise. They have no ownership over their decisions. They are just following directions.
How to get to the next level: The novice is dependent on you, the educator, to explain the situation, give guidance on how to move through it and debrief what happened. Each iteration gives them more rules and exposure to context.
Context: Imagine a first year medical student shadowing you in the emergency department.
2. Advanced Beginner – You are aware of your incompetence
The advance beginner is able to start to apply context to the rules. They have a background knowledge that allows them to understand nuances as to why some rules are generalizable verses others require specific details to be true.
How to get to the next level: The advance beginner needs more experience and external feedback. For them, each iteration is a chance to try to absorb more context that will better allow them to apply the rules on their own.
Context: This is what 3rd year clerkships are for, and probably where most interns start.
3. Competent Performer – Taking ownership of your incompetence
The competent performer begins to realize they don’t have, and never will have, enough rules for every situation. Thus they create broader “rules” such as maxims that they can apply to multiple contexts. Ultimately, they are creating a decision-making process of their own. They have the capacity to review their actions and elicit an emotional response to the outcomes (Dreyfus). They feel responsible.
How to get to the next level: Help the competent performer to reflect. Guide them to replay the events and make their own determinations of what worked and what didn’t. More important than the specifics will be the maxims – general truths – that can be applied to their decision-making in a broad set of contexts.
Context: This is what a junior resident is striving to achieve.
4. Proficient Performer – Deliberately Competent
The proficient performer can easily recognize the bigger picture goals and the pertinent situational context. They can intuitively sort through which information is important, but they may need to think long and hard to analyze the data while making their decision. It is not automatic.
Hot to get to the next level: The proficient performer needs case-based learning in any format – real, simulated, or discussion. The more situations to which they can be exposed and practice their decision-making, the more automatic it will become. As one of my attendings, Dr. Sinert, always says, “More patients, more learning.”
Context: This is what a senior resident needs to graduate, and how we are able see more patients.
5. Expert – Automatically Competent
The expert no longer needs to think. They intuitively grasp the situations – goals and context – and react accordingly. They understand the subtle differences in context that may lead to subtly different decisions. Lyon succinctly boils it down to “fluid performance based on previous situations without obvious thought” (p. 89, Lyon).
Context: Most attendings operate in this realm.
How to get to the next level: Wait…is this a trick question? What’s next?
The Next Level - A deeper dive into learning and educating
The Master – the mindfully deliberate expert
The master is not part of the Dreyfus model because, appropriately, if the goal is performing a skill, there is no level beyond doing it perfectly and intuitively without thought. But, to be an educator, I think it is imperative to add “Master” to the stages. In popular culture, it is Malcolm Gladwell who has popularized the idea that 10,000 hours is necessary to master a skill. Gladwell came to this number from a study performed by a psychologist, Dr. K. Anders Ericsson. Ericsson has devoted a career to education models and what he calls “deliberate practice.” His sentinel study showed that expert violinists are not musical prodigies. They just practice more than everyone else. While non-experts had on average 4,000 hours of lifetime practice, experts had 10,000 hours (are you connecting the dots?).
For Ericsson, the discussion does not end at the number of hours, but the most productive way to use these hours. In his studies of surgeons, radiologists, and clinical interactions he has come to the conclusion that “deliberate practice” is a superior learning method. Ericsson defines deliberate practice as “the individualized training activities specially designed by a coach or teacher to improve specific aspects of an individual’s performance through repetition and successive refinement…To receive maximal benefit from feedback, individuals have to monitor their training with full concentration, which is effortful and limits the duration of daily training” (Ericsson, p1472). Ericsson would argue this is not only the difference between proficiency and expertise, but it is essential to maintaining expertise. His studies show that across many fields, without practice, people lose their skills. The expert must engage in deliberate practice to maintain their expertise. To be a teacher is to apply that same sense of deliberateness to your expertise. You have to understand your seemingly intuitive and automatic actions if you are going to impart them to someone else. This is mastery. To teach someone else, it is imperative to both strive for expertise and mastery.
As budding educators, don’t let the idea of mastery daunt you. The beauty of the model, both Dreyfus and Ericsson would agree, is that all skills move through the stages in isolation. One can be an expert at picking their nose, while a novice at snot rockets despite both being methods to expel snot. I make this point for two important reasons. The obvious is to apply this to our students. You may have to regularly juggle your teaching style to accommodate different skills being at different stages of expertise within one student or across a classroom. But secondly, it is to apply to us as educators. Being an educator takes many skills that might not all be at the same stage for us. You may be a proficient lecturer, while only an advanced beginner at bedside teaching.
On your journey to become a master educator, pause and reflect on your stages. Take time to engage in your own deliberate practice, and whether teaching a cartwheel or a central line, always remember:
- Assess your learner – they may be at different stages for different skills
- Tailor your teaching plan to the stage of your learner(s)
- Assess yourself as an educator and seek out the help you need to get to the next level
The references below offer much more depth and insight into the topic of education models and theories. I encourage you to explore them at your leisure and check out the November 2015 issue of Academic Medicine that focuses on mastery learning in medical education.
This post is dedicated to “mama NOLS” for all the National Outdoor Leadership School has taught me over the years and many thanks to Dr. James Willis for his support and feedback.
Benner, Patricia. “Using the Dreyfus model of skill acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education.” Bulletin of science, technology & society 24.3 (2004): 188-199.
Dreyfus, Stuart E. “The five-stage model of adult skill acquisition.” Bulletin of science, technology & society 24.3 (2004): 177-181.
Ericsson, K. Anders. “Acquisition and maintenance of medical expertise: A perspective from the expert-performance approach with deliberate practice.”Academic Medicine 90.11 (2015): 1471-1486.
Lyon, Lucinda J. “Development of Teaching Expertise Viewed through the Dreyfus Model of Skill Acquisition.” Journal of the Scholarship of Teaching and Learning 15.1 (2015): 88-105.
Peña, Adolfo. “The Dreyfus model of clinical problem-solving skills acquisition: a critical perspective.” Medical Education Online 15 (2010).
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