From the time of entry in to a medical college, over 4 to 6 years time, a novice medico is expected to acquire several competencies that go to make a competent doctor. The medical teachers need to construct the learning ladder as a progressive path to acquiring these competencies. This slide set explains the various "ladders" viz., Miller's Pyramid, Dreyfus competency stages and RIME framework and also Dunning-Kruger effect that explains why many novices do not acquire the competencies.

1. NOVICE to COMPETENT –
Constructing the Learners’ Ladder
Prof KR Sethuraman. MD PGDHE.
Sri Balaji Vidyapeeth, India
www.sbvu.ac.in

2. Skill – Competency – Competence
• Competency = Skills + knowledge +
behaviour
– e.g., problem solving, professionalism etc.
– the skills-set a person needs to perform a task
• Competencies, if acquired, lead to
competence
Competence is a person’s overall ability to
fulfill the requirement or task.
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3. IMG: Core Competencies
© 2013 Accreditation Council for Graduate Medical Education (ACGME)
CLINICIAN
LEADER COMMUNICATOR
PROFESSIONAL LIFELONG LEARNER
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4. MCI – Suggested Changes To Curriculum
• Competency based teaching-learning (CBT)
• Integration of ethics, values and
professionalism into all phases of learning.
• Emphasis on self-directed learning.
• Ensure confidence in core competencies
among all passing graduates
• Assessment of competencies & Feedback.
• Acquisition and certification of essential skills.
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5. Competency based teaching-learning (CBT)
• Designing & implementing a curriculum
that focuses on the desired and observable
abilities in the real life situations.
• How can we ensure that our graduates will
acquire these?
– By Curricular alignment at all stages to reduce
the achievement gap. (study the next slide…)
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6. Aligned
Curriculum 1
2
34
5
Intended Curriculum:
what competencies we
want student to acquire
Taught Curriculum:
engages students with
intended curriculum
Experienced Curriculum:
Students’ experience:
Differs from student to
student
Assessed Curriculum:
assessing what we want
them to learn
(competencies)
Achieved Curriculum:
Competencies they
have acquired after
undergoing the course.
Curricular Gap = Intended – Achieved
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7. Miller pyramid as a guide to Clinical
Teaching-Learning…
7
KNOW
KNOW HOW
SHOW HOW
DO
BE
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8. Mastery Learning Model

9. The Dreyfus Model of Skill Acquisition --
Stages in acquiring competency:
• Novice
• Advanced Beginner
• Competent
• Proficient
• Expert
• Master
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10. The Dreyfus Model – stage-1
• NOVICE: medical student at entry
– Context free rules (cookbook approach)
– Relatively inflexible behavior
– Beginning to gain experience
• Unconsciously Incompetent
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11. The Dreyfus Model – stage-2
• ADVANCED BEGINNER: Final year Medico / intern
– Episodic knowledge
– Beginning to link knowledge with experience
– Beginning to know when to apply rules
– Realises one’s own inadequacies in competence
• Consciously Incompetent
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12. The Dreyfus Model – stage-3
• COMPETENT: A graduating MBBS
– Knows what to do and, when, why and how to do it.
– Can determine what is and is not important.
– Has a model that can be used as a starting point in
most situations.
– Can initiate plans and monitor progress of the plan.
– Not yet fast, fluid or flexible.
• Consciously Competent { Are we achieving this? }
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13. The Dreyfus Model – stage-4
• PROFICIENT: After a few years of
independent practice.
– Readily formulates plans for care.
– Anticipates “most likely” occurrences.
– Recognizes departures from the expected course and
modifies plans accordingly.
• Unconsciously Competent
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14. Insight is needed at Stage-1
Learners tend to begin at
stage 1 - 'unconscious
incompetence'.
Insight leads to
stage 2 - 'conscious
incompetence',
Through practice, reach
stage 3 - 'conscious
competence‘
& with experience, end at
stage 4 - 'unconscious
competence'.
https://www.businessballs.com/self-awareness/conscious-competence-learning-model-63/
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15. Challenge in CBME
• Teachers often wrongly assume Learners to be
at stage 2 (I want to learn) and try to achieve
stage 3, when the Learners are still at stage 1:
– They are unaware of the skill, its relevance, own
deficiency, or of the benefits from acquiring the
new skill: “I know it” or “I don’t need this” fallacy
– learners may not see the need for learning the skill
– This is a fundamental reason for failure of
competency based medical education.
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16. • A cognitive bias wherein,
• unskilled students assess their ability to be
higher and suffer from illusory superiority
– (“I have seen it; I can do it” fallacy)
• Conversely, highly skilled teachers may
erroneously assume that tasks that are easy
for them are also easy for others
– (“anyone should be able to do it” fallacy)
Kruger, Justin; Dunning, David (1999). “Unskilled and Unaware of It” doi:10.1037/0022-3514.77.6.1121.
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Dunning & Kruger Effect

17. Eg1: Non-Learning of Physical Exam (1987)
• "Ignore and be Ignored" –
often backfires in clinical exams
– Sphygmomanometry with
mercury column kept horizontal
on the bed!
• (Pt’s BP read 300mm!)
• The student had only seen
others recording BP – never
attempted it till the exam-day!

18. Promoting Clinical Competence among
All Medicos – 1987 onwards…
MISSION
• Every student must perform 'must do' skills
• Observe each one & give corrective feedback
to try and eliminate learning errors
METHOD
• Innovative use of OSCE for remedial
education
K. R. Sethuraman (2009) The use of objective structured clinical examination (OSCE) for detecting
and correcting teaching-learning errors in physical examination, Medical Teacher,15:4, 365-
368, DOI: 10.3109/01421599309006658

19. Eg-2: Learning of Communication skills (1988)
• Intended Outcome:
– “All medical students should be able to converse in
Tamil to elicit clinical history from patients.”
• Resources: a 16-page booklet on “clinical Tamil”
with instruction – Failed for 2 years (1986-’87)
as the students were “not convinced…”
• A motivational talk and anecdotes from an
alumnus in Mizoram and a few more in USA
made them want learn the local language.
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20. Motivation is Vital for CBME to Succeed
• People only respond to training
– when they are aware of their own need for it, and
– the personal benefit they will derive from
achieving it.
• It's vital to establish awareness of the training
need to be conscious of incompetence, prior
to imparting skills to progress to conscious
competence.
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21. Foresee Conf 21
II MBBS III-IV MBBS CRRI With
Experience

22. Step-wise Competency Assessment
• Assessment of students’ competency should
be fine tuned to match the level expected
– e.g., A checklist for auscultation skill for 3rd
semester students differs from one to assess the
9th semester students …
• RIME framework helps us to plan the
milestones for skills acquisition through the
semesters 1 to 9.
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23. Miller pyramid as a guide to
Evaluation of Competency
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24. Competency Is Not Enough
• Professional Identity Formation in Medical
Education Through
– Reflection,
– Relationship,
– Resilience
– https://journals.lww.com/academicmedicine/Fulltext/2015/060
00/Professional_Identity__Trans_Formation_in_Medical.8.aspx
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Professional identity ensures
Performance

25. Initiatives at Sri Balaji Vidyapeeth
• STEPS© Curriculum for MBBS –
– (Student-centric, Trans-disciplinary, Experiential,
Problem-oriented, Self-directed)
– Includes Exit-OSCE for outgoing interns
• Competency based PG training (CoBaLT©)
• SCORE© (Systematic Competency ORiented
Education) for Dental CRRI
• OSCE for Core-skills Assessment in Nursing
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Mail to registrar@sbvu.ac.in for further info

26. Spider-Graph assessment
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Exit OSCE Result of an outgoing intern

27. Summing Up…
• Motivation and Resources are both essential
for CBME to succeed and sustain
• The higher level outcomes of competencies
take time & effort to be achieved,
• We have to assess them repeatedly in a
formative manner with corrective feedback
• Well crafted assessment tools are needed to
follow Rene’ Dubois’s advice:
– “Assess the important – not the most convenient”
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28. Thank You All…
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