How do students develop mastery?

Revisiting the model of skill acquisition by the Dreyfus brothers:

• novice
• advanced beginner
• competent
• proficient
• expert

Students gain skills stepwise. Initially, as the novice, they require all the mental efforts to be focused on the task at hand. They cannot handle distractions.

As an expert, our blind spot is recognizing the amount of effort it takes for students to engage in these tasks. We chunk tasks together and perform them effortlessly, without thought.

For our students we need to unpack tasks into manageable component parts, let them practice each part separately until mastered, then move on to the next task. Finally they can reassemble them back into the whole.

So it is unrealistic to ask novice students to assess an undifferentiated patient. They have no idea how to do so. And the amount of data coming at them is overwhelming. Instead, we can decompose this into component pieces. In the diagram to the left, a task is broken down into three component pieces: P1, P2 and P3.

In order to assess an undifferentiated patient, you should:

1. Identify the chief complaint
2. Create a differential diagnosis based on that complaint
3. Create an illness script for each disease on that differential
4. Use the illness scripts to perform a history and physical
5. Determine how closely your patient fits your illness scripts, this is your pretest probability

To go further into testing would be overload at this point. Instead, allow the students to first master skill #1. Allow them to keep repeating until they can do it consistently. Then help them master skill #2. Then skill #3. Ultimately, put all the skill together.

Another process could be to order and interpret testing. In order to do so, you should

1. Given a diagnosis, assign a test threshold
2. Given that same diagnosis, assign a treatment threshold
3. Place the pretest probability within that spectrum
4. Decide whether testing is worth it or not

Each skill should be practiced in isolation until mastered before moving to the next one. When they’re all mastered, then practice putting it together.