Unconscious incompetence and the foundation years

One popular educational model suggests that trainees progress through the following sequence of competencies, and awareness of those competencies:

1. Unconscious incompetence

2. Conscious incompetence

3. Conscious competence

4. Unconscious competence

In our experience this model does not fit with training in emergency medicine. An additional first step can be added to represent the new senior house officer (SHO): that of initial conscious incompetence. We find that new SHOs are acutely aware of how little they know about many of the conditions they will see in the emergency department. Typically, as they grow in confidence, they progress through to unconscious incompetence, usually by about the 3rd or 4th month. Frequently something will happen to help them progress to the next step, conscious incompetence, through which they may or may not pass by the end of their 6‐month attachment. The two states of conscious incompetence are distinguished by improvements in knowledge and skills. Worryingly, proposals for foundation year 2 will result in many SHOs spending only 4 months working within our speciality. This could result in trainees leaving us in a state of unconscious incompetence.

Senior consultants may be interested to read that we have further developed our five‐ stage model. Most registrars and younger consultants reside happily in a state of conscious or unconscious competence. We are finding the issue of deskilling a significant concern. We anticipate adaptation. The full eight stage model looks like this:

1. Initial conscious incompetence

2. Unconscious incompetence

3. Conscious incompetence

4. Conscious competence

5. Unconscious competence

6. Conscious incompetence (intolerant of self)

7. Conscious incompetence (tolerant of self)

8. Conscious of incompetence in others, and intolerant