Table 4. Applying the Dreyfus Model to Surgical Competency.

Novice Is rule driven Uses analytic reasoning and rules to link cause and effect Has little ability to filter or prioritize information, so synthesis is difficult at best and the big picture is elusive	Medical Student/Intern Not able to perform majority of procedure even with supervision
Advanced Beginner Is able to sort through rules and information to decide what is relevant on the basis of past experience Uses both analytic reasoning and pattern recognition to solve problems Is able to abstract from concrete and specific information to more general aspects of a problem	Junior Resident Performs majority of the procedure with supervision
Competent Emotional buy-in allows the learner to feel an appropriate level of responsibility More expansive experience tips the balance in clinical reasoning from methodical and analytic to more readily identifiable pattern recognition of common clinical problem presentations Sees the big picture Complex or uncommon problems still require reliance on analytic reasoning	Senior Resident/Fellow Performs complete procedure with supervision Likely able to perform safely without supervision but has not yet done so
Proficient Breadth of past experience allows one to rely on pattern recognition of illness presentation such that clinical problem solving seems intuitive Still needs to fall back to methodical and analytic reasoning for managing problems because exhaustive number of permutations and responses to management have provided less experience in this regard than in illness recognition Is comfortable with evolving situations; able to extrapolate from a known situation to an unknown situation (capable) Can live with ambiguity	Fellow/Practicing Orthopaedist Repeatedly performs task successfully and independently
Expert Thought, feeling, and action align into intuitive problem recognition and intuitive situational responses and management Is open to notice the unexpected Is clever Is perceptive in discrimination features that do not fit a recognizable pattern	Practicing Orthopaedist/Professor Demonstrates advanced skill and is adaptable to handling unexpected surgical situations