From: Flyvbjerg, B. (2001) Making Social Science Matter: Why Social Inquiry Fails and How It Can Succeed Again, trans. Steven Sampson. Cambridge: Cambridge University Press, p.10.

Competence and virtuosity in human learning

Some years ago in the United States, an experiment was conducted on a group of paramedics. Video films were made of six persons administering cardiopulmonary resuscitation (CPR) to victims of acute heart failure. Five of the six were inexperienced trainees just learning CPR, while the sixth was a paramedic with long experience in emergency life-saving techniques. The films were shown to three groups of subjects: paramedics with practical experience, students being trained in this field, and instructors in life-saving techniques. Each subject was asked the following question: "Who of the six persons shown in the films would you choose to resuscitate you if you were the victim of such an accident?" Among the group of experienced paramedics, 90 percent chose the one experienced paramedic from the films. The students chose "correctly" in only 50 percent of the cases. Finally, and perhaps surprisingly, the instructors in resuscitation had poorer results than either the experienced paramedics or the students, choosing the experienced paramedic in only 30 percent of the case (see note 1).

What form of rationality led the instructors to achieve such a poor performance? And what mechanisms lay behind the experienced paramedics' well-developed ability to choose correctly? These questions will be dealt with in the following discussion.

Detailed phenomenological studies of human learning indicate that people pass through several phases or levels in the learning of skills, where "skills" are understood to range from the technical to the intellectual;

e.g., building a house, being socially adept, analyzing a text. Various studies, all after the degree of detail, have divided the learning process into a varying number of such levels. The Dreyfus model operates with five levels in the human-learning process:

(1) Novice

(2) Advanced beginner

(3) Competent performer

(4) Proficient performer

(5) Expert

They are levels, say Dreyfus and Dreyfus (1988), because in phenomenological terms they consist of recognizable, qualitatively different ways of acting and performing in the process of learning a given skill. Individuals at a given level do better than individuals at the previous level. Not all people achieve the highest level in a given field. Some fields, such as chess, guitar playing, or surgery, are characterized by only a small fraction of novices becoming experts. In other areas, such as bicycling and driving, a large number of novices reach the expert level.

The key to the model is gaining an understanding of the concepts contained within the five levels. Dreyfus identifies levels 1 to 5 and names them novice through to expert. It is best viewed as a continuum. Novice would start from knowing nothing to being able to make a reasonable attempt at performing the skill. At the other end of the scale the expert gives the impression of having an intuitive knowledge, using the skill as an integral part of a suite of skills in a wide variety of situations. The generic descriptions are an attempt to draw out the key concepts seen at each level. The history taking example is a (rather long winded) attempt to demonstrate how the skill level progresses in a clinical context.

Using this approach we could require a student to reach level 2 in history taking by the end of year 3. Thus the student knows what is required; we have something to measure his/her progress with and 4^th year staff know what the student should be capable of and can therefore build on that experience. The advantage of this model in the later years of the programme is that it recognises the complexity of skills usage in real life.

Skill level description	Generic description		Example: taking a history
Level 1 Novice	Rules	Focus on getting it right	Basic understanding of why history is needed. Working from a list of what questions to ask and how. No clear idea of what is important. History by numbers/checklist approach. Focus is on immediate task. Each step has to be thought through. Only responsibility is to get the history. Requires close supervision and guidance.
Level 2 Advanced beginner	Rules + situation	Still trying to get the skill right but starting to relate to other skills and/ or situations	Putting the task into perspective e.g. can see the need for different emphasis depending on situation. Still works through the list of questions and focus remains on, and responsibility with, the task in hand. Picking up more subtle cues from patient. Requires close supervision and guidance.
Level 3 Competent Performer	Rules + selected contexts. Accountable	Able to carry out the skill correctly and relating it to the wider picture.	Has developed a systematic approach which differs to suit the situation. Allows greater (but guided) patient contribution. Sees the skill in the wider context of care (the results of their deliberations may impact on the patients treatment) so greater personal ownership. Using a range of communication skills to elicit the information. Information is generally reliable but may miss/misinterpret unexpected/complex issues. Starting to think ahead - if X is the situation then I need to find out about Y and we will need to carry out test Z. Still likely to gather some extraneous information. Supervision more towards what to do with the information.
Level 4 Proficient Performer	Accountable & intuitive. Immediately sees WHAT	Skill is an integral part of the repertoire. Still refers to guidelines for where to go from here.	Consistently produces accurate and concise history. Focuses on points that matter, little extraneous materials and information put in context. Developing a rapport with patient. Working through implications of information whilst collecting it. Will immediately decide on what tests required and treatment for common situations based on guidelines and protocols. The skill is embedded in other related skills (eg communications, physical examination) forming part of a wider picture.
Level 5 Expert	Immediately sees HOW	Rapidly & accurately sums up the situation and seamless move to how to deal with it.	As for proficient but able to deal with far more complex cases in a similar manner. Little reference to guidelines (these are the people who write them) so they are applied automatically. Exceptions to the rule are a challenge to be met requiring more conscious thought.

Reference:

Mind Over Machine: The Power of Human Intuition and Expertise in the Era of the Computer by Hubert L. Dreyfus, Stuart E. Dreyfus, and Tom Anthanasiou (New York: Free Press, 1986, revised 1988)

Note:

1. Helen A. Klein and Gary A. Klein, "Perceptive, Cognitive Analysis of Proficient Cardio-Pulmonary Resuscitation (CPR) Performance." Paper presented at the 1981 Meeting of the Midwestern Psychological Association Chicago, here cited from Dreyfus and Dreyfus, Mind over Machine, pp 200-1.