EDUCATORS SERIES

Climbing the Ladder from Novice to Expert

Plastic Surgeon
Robert A. Weber, M.D.
H. Thomas Aretz, M.D.
Temple, Texas; and Boston, Mass.
Summary: This article reviews the nature of novice and expert thinking and
shows how pattern recognition is a key distinction between the two. The article
also discusses the ladder that learners climb as they move from medical student
to senior staff surgeon and suggests ways of viewing surgical trainees as they
progress through the process so that learning activities can be adopted that best
fit them. (Plast. Reconstr. Surg. 130: 241, 2012.)
O
n any day in the surgeons lounge, you can
see medical students learning to tie knots
onarmchairs, residents reviewing the steps
of an operation, and senior staff working through
the best way to manage an unexpected outcome.
How did we move from novice to expert? In a
related vein, as teachers we have learned that it is
a good technique to ask students questions to en-
gage them in active learning. Why, then, does the
Socratic method work so well with one group of
residents and so poorly with another?
Expertise is not passively acquired by increas-
ing experience. Practice makes permanent, not
perfect. Expertise is about improving perfor-
mance and not the routine completion of rote
tasks. Deliberate practice is one concept that at-
tempts to capture this distinction.
1
We know that
meaningful learning and progression of skills
takes place when learners are challenged, given
feedback through experts or coaches, and pro-
vided the opportunity to practice and learn. Ex-
pert plastic surgeons approach challenges in a
different fashion than surgical interns. Knowing
these differences can allow teachers and students
to design learning activities to promote the pro-
cession from novice thinking to expert thinking.
At the same time, cognizance of the various stages
along the continuumand a learners state of mind
as a result of their location on that path can help
a teacher use techniques appropriate for a partic-
ular learner. This gives the student surgeons in-
sight into to why they may respond the way they do
in certain situations.
FROM FIRST YEAR RESIDENT TO
SENIOR STAFF SURGEON
Novice versus Expert Thought Processes
The expert plastic surgeon differs from the
intern in more than just fund of knowledge. Al-
though it is true that a senior surgeon knows more
about plastic surgery than a postgraduate year-1
plastic surgery resident, what really separates them
is their varying thought processes. A typical prob-
lem-solving loop and its standard stages are
shown in Figure 1, left.
What Is the Problem?
This requires the surgeon to recognize that
there is a problem, determine its various parts and
their meaning, and prioritize the various aspects
of the problem according to importance. Experi-
enced surgeons are able to recognize when things
are out of the ordinary and see the problem. They
can easily break the situation down to its compo-
nents, recognize patterns, and then prioritize ac-
cording to importance.
2
Novices often have diffi-
culties distinguishing normal from abnormal,
cannot identify the parts of the problem or rec-
ognize patterns, or determine what is important.
These are skills that can be learned and practiced
(e.g., Bowdens suggestion of asking a learner to
summarize the important aspects of a case into
one sentence).
3
What Are My Options?
Rarely do problems have only one solution.
Whereas experts have learned to streamline the
From the Department of Surgery, Division of Plastic Surgery,
Scott & White Healthcare/Texas A&M Health Science Cen-
ter College of Medicine, and Harvard Medical School and
Harvard Macy Institute.
Received for publication October 4, 2011; accepted January
3, 2012.
Copyright 2012 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e318254b374
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.
www.PRSJournal.com 241
process of formulating treatment plans and
backup options through use of analogies and spe-
cialized routines, novices are prone to trial and
error, exhaustive but often irrelevant inquiries,
and exclusion of pertinent data based on initial
biases.
4
Unlike experts, novices do not have sig-
nificant expertise and experience in applying gen-
eral problem-solving techniques to a large set of
specific cases.
5
What Is My Decision? What Do We Do?
Experts often make use of shortcuts when
making decisions, which may be superior to de-
tailed decision algorithms, provided that the de-
cision maker is able to recognize the exceptions.
6
Novices are not capable of doing this but need to
rely on cumbersome, detailed, and often iterative
means of coming to a decision.
Actions
Clearly, what experts do and howthey perform
differs quite dramatically from the way novices do
things and their level of performance. The next
section addresses some of the issues concerning
skills.
Are We Done and What Have We Learned?
This last step is one that defines deliberate
practice and one of the major differences between
novices and experts. Experts always reflect to ex-
amine what they could have done better, and
what the essence of the experience was that can
be taught to others. Novices should be encour-
aged to reflect, but self-assessment requires a
certain base level of knowledge, and teachers
need to encourage reflection by beginners by
modeling self-reflection.
7
Figure 1, right, illustrates the distinctions dis-
cussed above. Overall, the chief attributes of an
expert as opposed to a novice are pattern recog-
nition and ability to process discordant or incom-
plete data (Table 1).
811
Although a fund of knowl-
edge is critical and must be developed, the seasoned
plastic surgeon does not have all the answers but
does know how to make decisions without complete
information.
12
Knowing the characteristics of expert thinking
allows plastic surgery educators to develop curri-
cula that begin with the dissemination of infor-
mationandalsoinclude discussions of context and
patterns. Pangaro developed the RIME schema of
developing these capabilities.
13
Dividing the various
stages into the categories of reporter (reliable data
gathering and reporting), interpreter (prioritizing,
analyzing, synthesizing), manager (presents options
and makes decisions), and educator (posing new
questions, teaching), the authors created a develop-
mental schema for clinical reasoning and decision
making.
The Developmental Ladder
Building on their study of chess players and
pilots, Hubert and Stuart Dreyfus published a
model of skills acquisition in 1980.
14,15
They found
that learners pass through levels of proficiency
change, from a reliance on abstract principles to
Fig. 1. (Left) Thevarious stages of problem-solving. Novices typically movearoundthecircle, whereas experts appear tobeable
tomovealongtheredarrow, shorteningtheprocess dramatically. (Right) Superimpositionof skills andcharacteristics of experts
that enable them to accomplish this (see text for details).
Plastic and Reconstructive Surgery July 2012
242
the use of past experience, and adjust from anal-
ysis of all data that are equally important to the
recognition of key relevant data as described
above. William Howell, working in the field of
communications, writes of similar findings and
describes a competence ladder with four stages:
Stage 1: Unconscious incompetence. Learners
are unaware that they do not have a particular
competence.
Stage 2: Conscious incompetence. Learners know
that they want to do something but are unable
to do it.
Stage 3: Conscious competence. Learners can
achieve a particular task but must think about
every step.
Stage 4: Unconscious competence. Learners no
longer have to think about knowing or per-
forming a task.
16
Using Howells system, the conscious compe-
tence ladder gives insight to learners and guid-
ance to teachers. During the conscious incompe-
tence phase, residents have the reassurance that
although learning is frustrating, the situation will
improve. At the stage of unconscious competence,
the model reminds residents to value the skills
acquired and show compassion to those behind.
Teachers can be aware of the emotional aspects
associated with learning and adjust methods ac-
cording to the level of their resident.
In preparing to review the ladder, there are
important principles to keep in mind. First, there
are other theories about moving from novice to
expert (e.g., Dreyfus outlines a five-step process
that has been the basis for much useful research
and application).
5,15
These steps are generaliza-
tions intended to begin to give insight. Second,
people move up at different rates, and there is no
set time for each stage. Some residents achieve a
level but fail to make the jump to the next step.
The learning process is spiral in nature, and some
learners move forward more easily in some areas
than in others. At times, it can seemthat a resident
moves backward.
17
This is why many postgraduate
year4 plastic surgery residents are discouraged
during their first few months of plastics residency:
they moved from being consciously competent
surgeons to consciously incompetent plastic sur-
geons. Astudent canbe a novice insome areas and
expert in another. Furthermore, a single class can
have students in various stages.
THE FOUR RUNGS
1: Unconscious Incompetent (You Do Not
Know That You Do Not Know)
Inthis stage, the learner is not cognizant of the
existence or relevance of many of the skill areas,
not aware of a particular deficiency in the area of
concern, and must become conscious of his or her
incompetence before development of the new
skill or learning can begin (Figs. 2 and 3).
16,17
Medical students in their final year and approach-
ing their specialty choice are frequently on this
rung of the ladder. As Dreyfus points out, when
the awareness of skill and deficiency is low or
nonexistent, the trainee or learner will simply not
see the need for learning.
15
It is essential to es-
tablish awareness of a weakness or training need
before attempting to impart or arrange training or
skills necessary to move trainees from stage 1 to
stage 2. Teachers and trainers commonly assume
trainees are at stage 2, and focus effort toward
achieving stage 3, when often trainees are still at
stage 1. This is a fundamental reason for the fail-
ure of a lot of training and teaching.
15
Table 1. Contrast between Novice and Expert Thinking*
Novice Expert
Inflexible (rule-bound, dogmatic) Flexible (adapt to circumstances)
Slow, hesitant, lacks confidence Fast, fluid, confident
Cannot access needed knowledge network quickly Instantly retrieves pertinent knowledge network
Emotions take over (seek stress reduction) Remains calm; does not act until necessary
Focus; addresses surface features of problem Focus; addresses source of problem
PET shows whole brain active PET shows part of brain active
Less than five experiences with similar problems More than five experiences with similar problems
Uses trial and error to solve Narrows down and rules out
Avoidance of premature closure/anchoring, faulty
synthesis, and omission
Does not jump to conclusions, recognizes A B C
syndrome, includes key data in decision making
PET, positron emission tomography.
*Data from Johnson P. The acquisition of skill. In: Smyth MM, Wing AM, eds. The Psychology of Human Movement. Orlando: Academic Press;
1984:215239; Druckman D, Bjork AR, eds. In the Minds Eye: Enhancing Human Performance. Washington, DC: National Academy Press; 1991;
Haier RJ, Siegel BV Jr, MacLachlan A, Soderling E, Lottenberg S, BuchsbaumMS. Regional glucose metabolic changes after learning a complex
visuospatial/motor task: A positron emission tomographic study. Brain Res. 1992;570:134143; and Voytovich AE, Rippey RM, Jue D. Diagnostic
reasoning in the multiproblem patient: An interactive, microcomputer-based audit. Eval Health Prof. 1986;9:90102.
Volume 130, Number 1 Nature of Novice and Expert Thinking
243
The goal for the unconscious incompetent
plastic surgeon is to build a knowledge network on
whichto place his or her newknowledge.
5,9,15
With-
out a framework, there is no place to put new facts
about diagnoses and treatment options. At the
same time that new nodes are being formed and
the fund of knowledge is increasing, the novice
surgeon is introduced to the basic tools of think-
ing like a plastic surgeon.
18
Before a learner can
recognize a pattern, there must be items present
that can be arranged and sorted, and rudimentary
processing algorithms available.
5,19
2: Conscious Incompetent (You Know That You
Do Not Know)
The postgraduate year2 plastic surgery resi-
dent is the classic example of someone on this
rung of the ladder (Fig. 4). At this level, the stu-
dents are beginning to realize that there is more
that they do not know than that which they do
know, and the more they learn, the greater their
realized ignorance becomes.
16
As a result, their
confidence drops.
17
This is a very uncomfortable
period, and residents in this stage can easily
become defensive.
20
Trainees can exist in this state for a long time,
depending on factors such as determination and
capacity to learn and the real extent to which an
individual is teachable. The teachers role in this
stage is tocome alongside the learner tosupport and
encourage.
15,21
The learner creates stress for himself
or herself. In wanting the resident to take on more
responsibility, the teacher must be careful tonot add
any stress other than that which the situation pro-
vides. The teacher can help the student make a
commitment to work through this difficult stage,
learn and apply the new plastic surgery concepts,
and move to the conscious competence stage.
18
The goal for the conscious incompetent plas-
tic surgeon is to begin to identify classic, common
Fig. 2. The developmental ladder. After explaining the rung, the chief character-
istics are identified, and key needs and areas to avoid are listed.
Plastic and Reconstructive Surgery July 2012
244
patterns and use well-established problem-solving
tools. The student still needs to add to the fund of
knowledge, but recognition of context and ability
to synthesize between knowledge nodes becomes
critical.
15
The learner is beginning to be able to see
common elements among ideas and skills that
seem disparate on the surface.
5
A catalog of anal-
ogous situations is begun.
5
As learners gain the
ability to recognize patterns, they should be given
at least one criterion-standard solutiona short-
cut, as it were.
18
A confident ability to make a
correct diagnosis, understand the disease, and
have a plan to treat the patient leads the maturing
plastic surgeon to the next rung.
3: Conscious Competent (You Know That You
Know)
At this stage, the increasingly able plastic sur-
geon acquires the new skills and knowledge of the
discipline much faster and more easily (Fig. 5).
The chief resident is frequently standing on this
rung. Here, the learner puts learning into practice
and gains confidence in carrying out the tasks or
jobs involved. The student is aware of his or her
new skills and works on refining them. The sur-
geon is still concentrating on the performance of
these activities, but with practice and experience,
these become increasingly automatic.
17
Becoming consciously competent often takes
a while, as the individual steadily learns about the
new area, through either experience or more for-
mal learning. This process can go in fits and starts
as the young plastic surgeon learns, forgets, pla-
teaus, and starts anew.
17
The more complex the
new area and the less natural talent present, the
longer this will take.
In this stage, the learner will need to concen-
trate and think to recall the knowledge or perform
the skill. The plastic surgeon is able to performthe
skill without assistance but is unlikely to be able to
teach it well to another person. The student must
continue to practice the new skill and commit to
becoming unconsciously competent, with prac-
tice being the single most effective way to move
from stage 3 to stage 4.
The goal for the conscious competent plastic
surgeon is to be able to recognize common pat-
terns easily, catalog analogies containing greater
variability, accrue an increasing number of short-
cuts, and develop specialized routines.
18,22
The
greatest danger is the rigid adherence to knowl-
edge, skills, and rules. Occasionally, the stress level
has to be raised to motivate the surgeon, who
knows that he knows, to keep learning.
5
Mastering
how a plastic surgeon thinks becomes more im-
portant than mastering what a plastic surgeon
knows; process begins to take precedence over
content.
19
4: Unconscious Competent (You Do Not Think
about Knowing)
Eventually, a plastic surgeon reaches the top
rung, the level where new skills become habits and
tasks are performed without conscious effort and
with automatic ease (Fig. 6).
17
This is the senior
staff surgeon. Johnson and Pratt note five charac-
teristics of a master plastic surgeon.
23
First, expert
surgeons possess great amounts of knowledge in
surgery and are able to apply that knowledge in
difficult practice settings. Second, the expert has
a well-organized, readily accessible knowledge net-
work that facilitates the acquisition of new infor-
mation. Third, expert plastic surgeons have well-
developed repertoires of strategies for acquiring
new knowledge, integrating and organizing their
networks, and applying their knowledge in a va-
riety of contexts. Fourth, an expert is motivated to
Fig. 3. The unconscious incompetent learner.
Fig. 4. The conscious incompetent learner.
Volume 130, Number 1 Nature of Novice and Expert Thinking
245
continue to learn and increase mastery. Fifth, the
unconsciously competent plastic surgeons appear
tobe able toaccess actions, recognitions, andjudg-
ments spontaneously during their performance,
often unaware of having learned to do these
things, and usually unable to describe all of the
details of how they are able to accomplish the task.
The expert is intuitive; pattern recognition
and matching occur on a subconscious level. As a
result, the person might be able to teach others in
the skill concerned, although after some time of
being unconsciously competent, the expert might
actually have difficulty in explaining howhe or she
does itthe skill has become largely instinctual.
18
This gives rise to the need for long-standing un-
conscious competence to be checked periodically
against new standards.
24
CLIMBING THE LADDER
Learning activities should be structured to be
suitable for the stage of the learner. The novice
learner should be given ample opportunity to
watch experts and ask questions.
25
Answering a
question with a question is not helpful at this stage
but will become more so as the student gains a
greater fund of knowledge.
18
Journal club, where
the emphasis is on discussing the latest informa-
tion, is not very helpful to someone who has yet to
understand the basics. Simulations and case man-
agement scenarios will help unconscious incom-
petent learners become conscious of what they
need to know; the opportunity to play surgeon
will motivate the beginner to move forward.
18,26
The conscious incompetent learner should be
given hands-on experience with basic patients and
techniques.
15
Complex clinical scenarios should
be broken down into more basic components and
the learner given simple problems to solve.
18
The
focus should be on the facts, concepts, and tech-
niques that the plastic surgeon in training must
know. Students should be asked to discriminate be-
tween correct and incorrect information and ac-
tions. Classic presentations should be emphasized.
18
This is in contrast to the conscious competent
surgeon, who needs to be challenged with unusual
presentations and more autonomy, moving from
direct to indirect supervision.
18
Journal club is
helpful at this stage; morbidity and mortality con-
ferences remind the mature surgeon that there is
still more to be learned.
27
The unconsciously com-
petent surgeon is ready to begin by developing
learning activities and partaking inpeer-group dis-
cussion. By taking on the responsibility of teach-
ing, the master plastic surgeon is forced to think
through the steps of knowing, and challenged to
stay current in plastic surgery.
As teachers, it is important to ask questions
appropriate for the learners stage. Helpful ques-
tions for the unconscious incompetent learner are
the who, what, where, andwhen questions.
26
The
questions should be about the fundamental facts
and principles of plastic surgery.
5
When a budding
plastic surgeon asks a question, it should be an-
swered fully and then the novice should be en-
couraged to read more about it.
18
It is also helpful
to think out loud and show the learner how the
answer is derived.
18
Questions about why and
differential diagnoses begin to show the context
for the facts and help the learner move to the next
stage.
Questioning the conscious incompetent learner
requires tact. The teaching surgeonshould establish
a safe environment for questions and reassure the
resident of the purpose of the questioning.
17
The
conscious incompetent learner is best helped with
comparison and contrast inquiries. Learners in
this stage should be asked to make decisions and
Fig. 5. The conscious competent learner.
Fig. 6. The unconscious competent learner.
Plastic and Reconstructive Surgery July 2012
246
justify them. What if questions are excellent to
begin to move the learner to the conscious com-
petent stage. This resident shouldalsobe askedfor
backup plans and exceptions to the rule.
17
The
surgeon at this stage should be given questions
for which the answer violates well-established
patterns.
5
A helpful question for the unconscious
competent learner is, Howwould you explain this
to someone else?
Patience is the watchword for practitioners on
all rungs of the ladder. On one hand, it is impor-
tant for plastic surgeons on the first three rungs to
consciously bring to mind the fact that progress
takes time. The knowledge and skills they see dem-
onstrated are the result of significant time spent
learning. On the other hand, the senior plastic
surgeon must remember to be patient with those
who are now climbing the rungs he or she stood
on a short while ago.
AT THE TOP
Although mastery of plastic surgery is the goal
of every novice, perfection is not possible. As a
result, we spend our lives as both teacher and
student simultaneously. The senior surgeons re-
sponsibility is to fuel the enthusiasm of the un-
consciously incompetent, soothe the insecurities
of the consciously incompetent, loosenthe rigidity
of the consciously competent, and engage the wis-
dom of the unconsciously competent. The chal-
lenge is to stand on the top rung, steady and firm,
so that the plastic surgeons after us can use our
shoulders as the next rung and see farther than
we can.
Robert A. Weber, M.D.
Scott & White Healthcare
2401 South 31st Street
Temple, Texas 76508
rweber@swmail.sw.org
REFERENCES
1. Ericsson KA. Deliberate practice and acquisition of expert
performance: A general overview. Acad Emerg Med. 2008;15:
988994.
2. Norman GR, Brooks LR, Cunnington JP, Shali V, Marriott M,
Regehr G. Expert-novice differences in the use of history and
visual information from patients. Acad Med. 1996;71:S62
S64.
3. Bowen JL. Educational strategies to promote clinical diag-
nostic reasoning. N Engl J Med. 2006;355:22172225.
4. Regehr G, Norman GR. Issues in cognitive psychology: Im-
plications for professional education. Acad Med. 1996;71:
9881001.
5. Carraccio CL, Benson BJ, Nixon LJ, Derstine PL. From the
educational bench to the clinical bedside: Translating the
Dreyfus developmental model to the learning of clinical
skills. Acad Med. 2008;83:761767.
6. Gigerenzer G. Less is more in health care. In: Gut Feelings: The
Intelligence of the Unconscious. New York: Penguin Books; 2008:
158178.
7. Hodges B, Regehr G, Martin D. Difficulties in recognizing
ones own incompetence: Novice physicians who are un-
skilled and unaware of it. Acad Med. 2001;76:S87S89.
8. Johnson P. The acquisition of skill. In: Smyth MM, Wing AM,
eds. The Psychology of Human Movement. Orlando: Academic
Press; 1984:215239.
9. Druckman D, Bjork AR, eds. In the Minds Eye: Enhancing
Human Performance. Washington, DC: National Academy
Press; 1991.
10. Haier RJ, Siegel BV Jr, MacLachlan A, Soderling E, Lotten-
berg S, Buchsbaum MS. Regional glucose metabolic changes
after learning a complex visuospatial/motor task: A positron
emission tomographic study. Brain Res. 1992;570:134143.
11. Voytovich AE, Rippey RM, Jue D. Diagnostic reasoning in the
multiproblem patient: An interactive, microcomputer-based
audit. Eval Health Prof. 1986;9:90102.
12. Chi CTH, Glaser R, Farr MJ, eds. Chapter 1. In: The Nature
of Expertise. Hillsdale, NJ: Lawrence Earlbaum; 1988:1528.
13. Pangaro LN. A shared professional framework for anatomy
and clinical clerkships. Clin Anat. 2006;19:419428.
14. Dreyfus HL. What Computers Cant Do: A Critique of Artificial
Reason. New York: Harper & Row; 1972 (Paperback edition,
1979).
15. Dreyfus S, Dreyfus H. A Five-Stage Model of the Mental Activities
Involved in Directed Skill Acquisition. Berkeley, Calif: Opera-
tions Research Centre, California University, Berkeley; 1980.
16. Howell WS. The Empathic Communicator. Belmont, Calif:
Wadsworth; 1982:2933.
17. Peyton JWR. The learning cycle. In: Peyton JWR, ed. Teaching
& Learning in Medical Practice. Rickmansworth, United King-
dom: Manticore Europe Ltd; 1998:1319.
18. Gookin J. Coaching for competence. In: 2004 NOLS Leader-
ship Educator Notebook. Lander, Wyo: National Outdoor Lead-
ership School; 2008:57.
19. Schon DA. Educating the Reflective Practitioner. San Francisco:
Jossey-Bass; 1987.
20. Perry WG. Forms of Intellectual and Ethical Development in the
College Years: A Scheme. New York: Holt, Rinehart, and Win-
ston; 1970.
21. Benner P. From novice to expert. Am J Nurs. 1982;82:402
407.
22. Mylopoulos M, Regehr G. How student models of expertise
and innovation impact the development of adaptive exper-
tise in medicine. Med Educ. 2009;43:127132.
23. Johnson J, Pratt DD. The apprenticeship perspective: Mod-
elling ways of being. In: Pratt DD, et al., eds. Five Perspectives
on Teaching in Adult and Higher Education. Malabar, Fla:
Kreiger; 2005:83103.
24. Mylopoulos M, Regehr G. Cognitive metaphors of expertise
and knowledge: Prospects and limitations for medical edu-
cation. Med Educ. 2007;41:11591165.
25. Lake FR, Hamdorf JM. Teaching on the run tips 5: Teaching
a skill. Med J Aust. 2004;181:327328.
26. Wales CE, Nardi AH, Stager RA. Emphasizing critical think-
ing and problem solving skills. In: Curry L, Wergin JF, eds.
Educating Professionals. San Francisco: Jossey-Bass; 1993:178
211.
27. Peyton R. Journal clubs and critical reading. In: Peyton JWR,
ed. Teaching & Learning in Medical Practice. Rickmansworth,
United Kingdom: Manticore Europe Ltd; 1998:131137.
Volume 130, Number 1 Nature of Novice and Expert Thinking
247