The Dreyfus model of clinical problem-solving skills acquisition: a critical perspective

Context: The Dreyfus model describes how individuals progress through various levels in their acquisition of skills and subsumes ideas with regard to how individuals learn. Such a model is being accepted almost without debate from physicians to explain the ‘acquisition’ of clinical skills. Objectives: This paper reviews such a model, discusses several controversial points, clarifies what kind of knowledge the model is about, and examines its coherence in terms of problem-solving skills. Dreyfus’ main idea that intuition is a major aspect of expertise is also discussed in some detail. Relevant scientific evidence from cognitive science, psychology, and neuroscience is reviewed to accomplish these aims. Conclusions: Although the Dreyfus model may partially explain the ‘acquisition’ of some skills, it is debatable if it can explain the acquisition of clinical skills. The complex nature of clinical problem-solving skills and the rich interplay between the implicit and explicit forms of knowledge must be taken into consideration when we want to explain ‘acquisition’ of clinical skills. The idea that experts work from intuition, not from reason, should be evaluated carefully

Frameworks for learner assessment in medicine:AMEE Guide No. 78

<p>In any evaluation system of medical trainees there is an underlying set of assumptions about what is to be evaluated (i.e., which goals reflect the values of the system or institution), what kind of observations or assessments are useful to allow judgments 1; and how these are to be analyzed and compared to a standard of what is to be achieved by the learner. These assumptions can be conventionalized into a framework for evaluation. Frameworks encompass, or "frame," a group of ideas or categories to reflect the educational goals against which a trainee's level of competence or progress is gauged. Different frameworks provide different ways of looking at the practice of medicine and have different purposes. In the first place, frameworks should enable educators to determine to what extent trainees are ready for advancement, that is, whether the desired competence has been attained. They should provide both a valid mental model of competence and also terms to describe successful performance, either at the end of training or as milestones during the curriculum. Consequently, such frameworks drive learning by providing learners with a guide for what is expected. Frameworks should also enhance consistency and reliability of ratings across staff and settings. Finally, they determine the content of, and resources needed for, rater training to achieve consistency of use. This is especially important in clinical rotations, in which reliable assessments have been most difficult to achieve. Because the limitations of workplace-based assessment have persisted despite the use of traditional frameworks (such as those based on knowledge, skills, and attitudes), this Guide will explore the assumptions and characteristics of traditional and newer frameworks. In this AMEE Guide, we make a distinction between analytic, synthetic, and developmental frameworks. Analytic frameworks deconstruct competence into individual pieces, to evaluate each separately. Synthetic frameworks attempt to view competence holistically, focusing evaluation on the performance in real-world activities. Developmental frameworks focus on stages of, or milestones, in the progression toward competence. Most frameworks have one predominant perspective; some have a hybrid nature.</p>