5Best Opportunity to Observe Stages Unstructured problemsNumber of potentially relevant facts enormousVariety of solutions extensive
6Novice The novice follows rules Specific rules for specific circumstancesNo modifiers“Context free”Don’t feel responsible for other than following the rule
7The early medical student is taught to obtain an EKG for chest pain, without other modifiers.
8Advanced Beginner New “situational” elements are identified Rules begin to be applied to related conditionsDecisions still are made by rule applicationDoes not experience personal responsibility
9The more experienced medical student finds that dyspnea also might be associated with cardiac ischemia and orders an EKG for that situation as well.
10Competence Numbers of rules becomes excessive Learn organizing principles or “perspectives”Perspectives permit assorting information by relevanceThe experience of responsibility arises from active decision-making
11The competent physician realizes the multitude of factors influencing the likelihood that a single symptom represents ischemia and has a decision tree to allocate probabilities balancing a number of factors in deciding when to order an EKG or other diagnostic modalities and begin treatment
12Proficiency Intuitive diagnosis Approach to problem molded by perspective arising from multiple real world experiences“Holistic similarity recognition”Learner uses intuition to realize “what” is happeningConscious decision-making and rules used to formulate plan
13The proficient physician realizes “this is an infarction” and then applies rules to decide about thrombolysis.
14Expertise Don’t make decisions Don’t solve problems Do what works No decomposition of situation into discrete elementsPattern recognition extends to plan as well as diagnosis
15“This is an infarction and we should implement the following diagnostic and therapeutic interventions.”
16When Expertise FailsThe expert uses rules and explicit decision-making.
17NoviceNovice: follows rules and does not feel responsible for outcomes.
18Advanced Beginnerrecognizes new situations in which the rules may be applied. Still does not feel responsible.
19CompetentFollows rules, applies an organizing “perspective” to determine what elements of the problem are relevant and feels accountable because of decision-making
20ProficiencyThe proficient learner uses pattern recognition arising from extensive experience to identify the problem (“what” is happening”) and rules and analysis in formulating the “how” of the solution. A sense of responsibility follows the decision-making.
21Expertiseimmediately sees “what” is happening and “how” to approach the situation. Pattern recognition extends to management plan as well as diagnosis.
22Dreyfus Model of Skill Acquisition The utility of the concept of skill acquisition lies in helping the teacher understand how to assist the learner in advancing to the next level.