Teaching in our local family practice residency is one of the most enjoyable parts of my week. When a colleague recently asked why I liked it so much, it took some reflection to answer.

There is considerable repetition in primary care, and many of the problems we see are pretty routine. Simple acute illnesses like sore throats, cough, ankle sprains, contact dermatitis are not terribly challenging. Even the basic initial approaches to chronic illnesses like diabetes, hypertension, asthma, or back pain are pretty straightforward. Most mature primary care clinicians no longer see these as intellectually stimulating, and it is too much work (and too slow) to think through the basic anatomy, physiology, pathophysiology, biochemistry, differential diagnosis, testing options and available therapies for every common problem. It becomes easy to slide into what Kahnemanndescribes as System 1 thinking: automatic and over-learned responses based on pattern recognition and intuition. 

Easy - but not ideal. And teaching can be one weapon against laziness and complacency. (The other is recognizing that while simple problems and many chronic diseases may be predictable and amenable to algorithms, patients are anything but. Focusing on each patient as an individual, where every circumstance is unique and requires a unique evaluation and plan, is the core of how I stay engaged and enthusiastic in actual practice. But teaching certainly helps.)

I use a framework involving five stages of competence:

  • Unconscious incompetence. This is the true novice, an individual who is unaware of the existence of relevant information/skills to master, tends to work off a recipe or with direct instruction, and is unable to self-regulate or self-correct. This person is learning the basic materials, usually must be assigned a very specific task and told what process to use and how to use it, often has to work out loud, and asks ‘Tell me what to do and how to do it.’
  • Conscious incompetence. This is an apprentice, an individual who has become aware of the existence of relevant information/skills to master, is beginning to acquire them, is aware of deficiencies, is committed to increasing competence and is learning how to identify the limits of competence. Supervision is essential, but direct supervision is less necessary, recipes are becoming internalized and can be combined and modified in limited fashion. The individual must still focus intently on the task, must self-consciously monitor their behavior to avoid mistakes, and functions poorly in ‘automatic’ mode or under stress. This person has learned much (but not all) of the basic material, can often correctly select the correct algorithm or process, is comfortable as long as the situation is predictable and the algorithm appears to be working, and asks ‘How can I do this better?’
  • Conscious competence. This is the journeyman, a competent individual who can reliably perform within the realm of his learning and is able to recognize what is beyond their competence. This person can modify or combine algorithms but must do it with conscious effort, and true curve balls, conflicts among learned patterns, or significant stress may impair performance. This individual can demonstrate but not teach, and is good at consciously combining previous recipes and practiced routines for the spaces between previously experienced circumstances, but has not fully integrated the material at a conceptual level and not ready to invent new algorithms for truly new situations. This person asks ‘How do I find a new algorithm or change the current one?’
  • Unconscious competence. This is the expert, an individual with enough practice in the previous stages that the information and skills have been truly integrated and feel intuitive and automatic. Everyone experiences this phenomenon in things like walking, driving, or getting dressed. This person prioritizes, merges algorithms, skips or adds steps unconsciously, and may consciously create new algorithms. This individual can teach, but is often unaware of the underlying algorithms or processes, and will often have to pause and examine the knowledge/skill in order to communicate it well. Not everyone in this category is able to explain what they do or why; we have all met experts who are unable to explain themselves in a way we find helpful. This person may sound less competent than the consciously competent individual who promptly rattles off the appropriate algorithm.  Automaticity here is common and appropriate,  but also dangerous because it can lead people to be unable to recognize error or the need for change. This person is comfortable in their expertise, is the hardest to teach, and is at great risk for losing the ability to recognize errors or change, and may become complacent and stagnate in a variation of the Peter Principle.  This person says “Here, let me show you a better way.”
  • Reflective competence. This is the enlightened master, an individual who has moved beyond being unconsciously competent to being able to function at the unconsciously competent level while simultaneously observing and questioning/challenging themselves. This is the guru, the ideal teacher and mentor, the person who has become bored with predictability and algorithms, who prefers to think things through, who likes to work based on principles rather than algorithms, who delights in (and may actively seek) the unfamiliar because they are motivated more by learning than by accomplishing. This person recognizes that ignorance is more important than knowledge and says “Help me find a problem whee I don’t already know the answer.”

At this stage in my career, it is seductively easy to be complacent and coast, enjoying the fact that much of what I see and do is familiar, comfortable and automatic. Teaching is a great antidote and forces me to strive for the fifth stage of reflective competence. Having to explain and justify what I do and why I do it, having to re-examine the approaches I have found successful, having to explicitly compare my approach to other options, having to think about whether I ‘know’ something or just assume it, these are some of the aspects of teaching that make it so rewarding.

In short, I love teaching because it helps me remain a learner.


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