Dreyfus Model of Skill Acquisition Craig McClure, MD EOSG University of Arizona March 2005

“To become competent you must feel bad” Hubert Dreyfus The quotation suggests that we change behavior because we are not content with existing behavior.

Activities Studied Airplane pilots, Chess players, Automobile drivers, Adult learners of a second language

Five Stages Novice Advanced Beginner Competent Proficient Expert

Best Opportunity to Observe Stages Unstructured problems Number of potentially relevant facts enormous Variety of solutions extensive

Novice The novice follows rules Specific rules for specific circumstances No modifiers “Context free” Don’t feel responsible for other than following the rule

The early medical student is taught to obtain an EKG for chest pain, without other modifiers.

Advanced Beginner New “situational” elements are identified Rules begin to be applied to related conditions Decisions still are made by rule application Does not experience personal responsibility

The more experienced medical student finds that dyspnea also might be associated with cardiac ischemia and orders an EKG for that situation as well.

Competence Numbers of rules becomes excessive Learn organizing principles or “perspectives” Perspectives permit assorting information by relevance The experience of responsibility arises from active decision-making

The 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

Proficiency Intuitive diagnosis Approach to problem molded by perspective arising from multiple real world experiences “Holistic similarity recognition” Learner uses intuition to realize “what” is happening Conscious decision-making and rules used to formulate plan

The proficient physician realizes “this is an infarction” and then applies rules to decide about thrombolysis.

Expertise Don’t make decisions Don’t solve problems Do what works No decomposition of situation into discrete elements Pattern recognition extends to plan as well as diagnosis

“This is an infarction and we should implement the following diagnostic and therapeutic interventions.”

When Expertise Fails The expert uses rules and explicit decision-making.

Novice Novice: follows rules and does not feel responsible for outcomes.

Advanced Beginner recognizes new situations in which the rules may be applied. Still does not feel responsible.

Competent Follows rules, applies an organizing “perspective” to determine what elements of the problem are relevant and feels accountable because of decision-making

Proficiency The 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.

Expertise immediately sees “what” is happening and “how” to approach the situation. Pattern recognition extends to management plan as well as diagnosis.

Dreyfus 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.