The Dreyfus model of skills acquisition (Table 1) describes different levels and aspects of practice in the spiral curriculum (Figure 2) from medical school to specialist training.

Table 1. Summary of the Dreyfus model of skills acquisition

Level 1: novice

  •  Rigid adherence to taught rules or plans
  •  Little situational perception
  •  No discretionary judgement

Level 2: advanced beginner

  •  Guidelines for action based on attributes or aspects (global characteristics of situations recognisable only after some prior experience)
  •  Situational perception still limited
  •  All attributes and aspects are treated separately and given equal importance

Level 3: competent

  •  Coping with crowdedness
  •  Now sees actions at least partly in terms of longer term goals
  •  Conscious deliberate planning
  •  Standardised and routine procedures

Level 4: proficient

  •  Sees situations holistically rather than in terms of individual aspects (see above)
  •  Sees what is most important in a situation
  •  Perceives deviations from the normal pattern
  •  Decision-making less laboured
  •  Uses maxims (whose meaning varies according to the situation) for guidance

Level 5: expert

  •  No longer predominantly reliant on rules, guidelines or maxims
  •  Intuitive grasp of situations based on deep tacit understanding
  •  Analytic approaches used only in novel situation or when problems occur
  •  Vision of what is possible

Source: Eraut, M. Developing Professional Knowledge and Competence (1994)

Understanding the five Dreyfus levels will enable foundation doctors to manage each stage of a patient's journey more effectively. They will steadily increase their expertise from having specific skills to managing the whole patient experience. They will gradually need less supervision.

Such models will also help supervisors and assessors expand what they look for in the foundation doctor's work and therefore make better judgements on their progress. In addition to using the F1 and F2 minimum levels of performance required for sign off to assess the progress of the foundation doctor, a supervisor/assessor might consider/ask:

  •  Is the foundation doctor using a more discerning mix of clinical understanding, protocols and guidelines?
  •  Is the foundation doctor carrying out procedures and making decisions more quickly?
  •  Can other team members describe how the foundation doctor has gained confidence in their decisions and their risk assessments?
  •  Are there fewer complaints from patients?
  •  Does the foundation doctor appropriately ask for help less often?

An alternative more graphic representation illustrates various levels of attainment, which might be achieved during foundation training.

Figure 1. Progression towards increasingly independent practice during the foundation programme (although every procedure or action is under supervision in the foundation programme)

Figure 1. Progression towards increasingly independent practice during the foundation programme (although every procedure or action is under supervision in the foundation programme)

In a spiral curriculum, progressive attainment involves increasing knowledge, skills and attitudes. This is illustrated in figure 2 showing the developmental stages involved in order to obtain consent for any procedure.

 

Consent for performance of any procedure

Figure 2. Example of the spiral curriculum

Figure 2. Example of the spiral curriculum

Based on: Harden RM, Davis MH and Crosby JR Medical Education; 31, 264. (1997)

It is evident, that increasing expertise correlates with more independent practice. An understanding of this progression will help foundation doctors and their trainers to (self-) assess and feedback/reflect more accurately upon clinical management.