Dreyfus Model of Skill Acquisition

Stuart E. Dreyfus, Hubert L. Dreyfus

The first patient Sarah presented to Darla was a 19-year old male with abdominal pain. Sarah recited her differential that she read from her book. “I am concerned for appendicitis, renal colic, and hernia,” she said. When Darla asked how Sarah planned to manage the patient, Sarah felt lost. She had learned that ultrasound could sometimes diagnose appendicitis, but she wasn’t sure about what do if the patient, in reality, had renal colic. “Why don’t we examine the patient together, and discuss each of the differentials you mentioned, and our management plan with the patient,” Darla replied, recognizing that Sarah needed to learn the basic rules, and approach to a patient with abdominal pain in the ED.

Darla reflected for a moment on how far she had come and how far she had to go. She knew she had progressed a great deal, but was unsure how to describe what differentiated her from Sarah. She also wondered how she would ever become so calm and comfortable as her attending, Dr. Glick. What were the steps she would need to take to progress to mastery?

In 1980, Stuart and Hubert Dreyfus published their seminal article, “A Five-Stage Model of the Mental Activities Involved in Directed Skill Acquisition.” Over the ensuing years, they refined their theory, and it was critically examined by experts in educational theory. While some have called into question the applicability of the Dreyfus model to certain situations and types of expertise, it is a useful framework for understanding the development of expertise and the creation of evaluation tools. More recently, this model had been applied to knowledge acquisition among medical practitioners. We will attempt to summarize the salient features of this theory, how it applies to medical knowledge, and explore modern takes on this model.

Dreyfus and Dreyfus argue that a learner will progress in a stepwise fashion through the stages of expertise. They open with the argument that descriptive studies, such as their original manuscript, offer valuable insights that cannot necessarily be provided by standard experimental models and maintain that their observations are “precise and replicable.” Through observation and systematization of changes in learners’ perception of the task environment, the authors characterize the stages of acquiring complex skills. The five stages include novice, competence, proficiency, expertise, and mastery.

Novice. In this initial stage, the task environment is broken down into “features,” which are parts of the task environment that the novice learner can identify without prior experience. He or she is then taught rules to respond to that feature. Through thoughtful feedback or self-reflection, the learner will improve and become more efficient at applying the rules to specific features.

Competence. This second stage of skill acquisition occurs only after the learner has obtained significant real-life experience. The learner begins to recognize patterns of repetitive features, which the authors term “aspects.” These aspects are no longer context-free, but are based on prior experiences. Responses to these contextual aspects can be scaffolded with guidelines, which instructors can provide. Guidelines, however, are not sufficient to prioritize specific situations, and thus do not weigh high-priority aspects differently.

Proficiency. The third stage of skill acquisition is termed proficiency, and occurs when the learner begins to develop broader situational awareness. What were originally valueless aspects, are now synthesized and prioritized, and the learner can draw from a wide base of typical situations. Irrelevant information is suppressed. Instead of following rules, learners now follow “maxims,” which are guiding principles that can be applied to different situations.

Expertise. When a learner has attained expertise, guiding principles such as rules, guidelines, and maxims are no longer necessary, as reacting to situations becomes intuitive. When faced with specific situations, appropriate responses are elicited. Intuition replaces the analytical approach. This stage is posited to be the highest level of mental capacity.

Mastery. The master can act intuitively as does the expert; but he/she can become so absorbed in the task that performance transcends even expert performance. It is suggested that at this level, the master no longer needs to provide cognitive attention to the task at hand, and rather can apply the mental energy he/she was using in monitoring and maintaining expert performance to perform at the highest level.

In their later article, “The Five-Stage Model of Adult Skill Acquisition” (2004), Dreyfus and Dreyfus expand to discuss not only the stepwise development of skill, but also break down components, perspective, type of decision making, and level of commitment at each stage.  They emphasize that only through emotional involvement and commitment to the task, the learner can advance beyond competence.

In their 2005 article, “Peripheral Vision: Expertise in Real-World Contexts,” the authors expand on their prior examples and apply their model to the physician, specifically surgeons, who are required to act quickly and spend little time deliberating. They provide take-home points which include:

1. Simple rule-following will never produce expert skill.
2. Avoiding errors is best accomplished by confronting mistakes when they occur, rather than building rules to prevent them.
3. When stakes are high, taking time for deliberation and reflection is important; however, one should avoid becoming analytical to a degree where he/she is no longer emotionally involved.

With the recent focus from the Accreditation Council for Graduate Medication Education (ACGME) on core competencies and how to assess them, Carraccio et al. proposed to use the Dreyfus model to show progression along this spectrum.  Even though the ACGME uses discrete markers (i.e., numbers) to mark progress on this scale, it has often been encouraged to look at it as a continuum of improvement of practice. The same can be said of the Dreyfus Model of Skill Acquisition. There were originally five proposed levels of proficiency which marked different benchmarks in acquisition and proficiency. Clinical competence can be viewed as a variety of skills that are acquired together to make an overall competent physician.

Dreyfus’ model emphasizes recognition, intuition, and reflection in order to develop professional skills.  These are all critical elements of physician training and improvement.  Medical students start as novices that often make rule-based decisions using hypothetico-deductive reasoning, argues Carraccio. They state that implementing problem-based learning (PBL) and an early introduction to clinical medicine could help students begin to recognize patterns and presentations of illness, allowing them to progress to the advanced beginner stage sooner in their training.

One main distinction in the work of Carraccio is that they have combined some of Dreyfus’ older and newer works, and have named six distinct stages of clinical skills acquisition.  The most notable of which is the distinction between expert and master. The danger with achieving the expert level is complacency secondary to the ease in which it takes to respond to the overwhelming majority of clinical encounters at this point in one’s career. This subsequently causes complacency or ‘autonomaticity’ as described by Bereiter and Scardemalia. They argue that individuals can either become experts (or masters in the Dreyfus model) or experienced non-experts, the latter being individuals who lack the drive for continuous improvement. Experts (or masters) desire more knowledge and continue to push beyond their own comfort zone in search of more complex problems and reinvesting one’s mental resources into the next challenge.

The hallmark skill of the master is practical wisdom. They are a practitioner who is able to easily impart wisdom upon others and is dedicated to lifelong learning.  This is done via constant self-assessment and self-regulation. Masters are emotionally engaged in every encounter and have concern for right and wrong decisions. Ultimately, this model could be very helpful in looking at the education of medical professionals throughout an entire career.  The stages it uses span from the foundations (i.e., medical school) all the way to decades of practice (i.e., mastery).  This makes it very advantageous, as progress could be marked without the other need for reference points.

Dreyfus SE, Dreyfus HL. A five-stage model of the mental activities involved in directed skill acquisition. Berkeley, CA: California Univ Berkeley Operations Research Center; February, 1980.

This is the foundational paper of the Dreyfus five-stage model. According to this model, a novice learner begins with a set of rules, which he/she is instructed to follow to respond to “features,” in the task environment. After the novice has obtained significant experience he/she will move to competence, wherein the learner begins to see the larger context and recognizes “aspects,” which are defined as recurrent features within the greater situational context. The learner moves to proficiency when he/she begins to recognize a great number of features, and individual situations now fit within the context of his/her considerable experience. The proficient learner follows maxims, which are guiding principles, rather than out-of-context rules. Expertise is obtained when the learner begins to act intuitively based on the combined repertoire of prior experiences. The final stage is termed mastery, and is described as the experience of performing without conscious effort. Examples of skill real-life skill acquisition include language learning, chess, and flying an aircraft.

Dreyfus SE. The five-stage model of adult skill acquisition. Bulletin of science, technology & society. 2004;24(3):177-181.

This article provides a summary of the 5-stage model, with examples of skill mastery, including driving and chess, and presents a framework for the steps regarding components (“elements of the situation that the learner is able to perceive”), perspectives, decision making, and level of commitment.

Dreyfus HL, Dreyfus SE. Peripheral vision: Expertise in real world contexts. Organization studies. 2005;26(5):779-792.

In this follow-up paper, Dreyfus and Dreyfus make the argument that decision making, especially in medicine, is not simply rule-based, but rather becomes intuitive as experience and expertise grows. The same analogies to driving and chess are again made, but are expanded to include medical decision makers. The authors make the argument that as decision makers become competent, they develop a growing sense of emotional involvement and this emotional involvement leads to progression. Finally, while experts grow to rely on instinct, the authors make the argument that when the stakes are high, careful deliberation and/or reflection are necessary.

Moulton CA, Regehr G, Mylopoulos M, MacRae HM. Slowing down when you should: a new model of expert judgment. Academic Medicine: Journal of the Association of American Medical Colleges. 2007;82(10 Suppl):S109-116.

In this article, the authors make the argument that development of expertise includes not only learning analytical processing, but also developing non-analytical processing, such as heuristics and illness scripts. Their argument is that experts must chose to slow down and rely on analytical processing when the situation is in the indeterminate zones of practice, in which case the situation does not fit well with prior experience.

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. Academic Medicine: Journal of the Association of American Medical Colleges. 2008;83(8):761-767.

The authors of this paper use a patient-care scenario to describe the development of a clinician, from early medical school through the well-seasoned attending who demonstrates mastery. Novice learners begin by learning rules and analytical reasoning. As the learner moves to the advanced beginner stage, he/she becomes able to organize and synthesize physiological cause and effect. As a learner becomes competent, illness scripts begin to emerge and emotional buy-in increases personal responsibility for the patient. Proficient learners become able to adapt prior illness scripts or to use pieces of prior illness scripts and extrapolate to new situations. A learner moves to the expert level when decision making becomes intuitive; however, he or she also becomes able to better discriminate phenomena that do not fit prior patterns. Mastery, often obtained only after years of practice, is characterized by practical wisdom, and goes beyond simple decision making to include the social and societal context of each situation.

The Dreyfus model looks almost exclusively at the automatic component of processing. The examples used in the earlier literature to describe the model were adapted from airplane pilots and learning how to drive a car. Both of these areas require significant thinking and concentration in the early stages, but eventually become almost entirely reflexive in nature, where actions are essentially automatic responses to stimuli, as perceived by the operator. It ultimately leads to effortless processing.

The Dreyfus model, therefore, is not well suited to address what happens when things do not proceed normally. Dreyfus acknowledges that there may be a component that requires effort on behalf of the expert; but this is ill defined, limited, and not elaborated upon. In medicine, the expert often engages in critical thinking, especially on more complicated cases or cases that do not present typically. The model of expert versus experienced non-expert from Bereiter and Scardamalia adequately addresses this deficiency. They posit that experts are constantly using reflective analytic tools to refine their analysis and better themselves. Experts are able to go from a routine, non-analytic approach, to a very focused and effortful process.

Ultimately, expert (or master) physicians will need to make the seamless transition from routine processing of a patient’s presentation of illness to one that is attentive and targeted.  This will allow them to be both efficient and effective in recognizing the various illnesses that they encounter on an everyday basis. Unfortunately, the Dreyfus model does not allow for this ‘flip-flopping’ that is necessary to avoid pitfalls and missed diagnoses.

He was glad to see that Darla saw the teaching moment, and correctly identified Sarah’s learning level. Over the last year, he had taught the residents how to teach learners of variable levels they may work with in the ED. He advises them, “You must first diagnose your learner.”

At the beginning of his talk on the topic, he tells them, “You start residency as a novice learner, or perhaps an advanced beginner. You will graduate as competent learners. My goal is to make sure that you value life-long learning, and have the skills and awareness for self-reflection and self-assessment to ensure that you continue to develop proficiency, and eventually become experts and masters in our field years after you graduate.”

Nothing gave him more satisfaction than watching the progress of his students and residents, and teaching them how to become effective educators themselves.