Unconscious Competence: Is the Procedure Over When the Skin is Closed? Or….

…. should the skin have been opened in the first place ??? 

In an interesting thread on Twitter, we have been discussing issues that surround certain non-quantifiable surgical skills. We teach residents how to diagnose certain problems.  We teach residents how to perform procedures.  We teach them how to recognize when a complication is likely to occur and how to avoid it.  We teach them numerous methods of addressing certain problem to prepare them for their careers as surgeons. 

Is that enough ???

An experienced surgeon who has reached the pinnacle of their career knows not only when a certain procedure is indicated, but, more important, they have learned (for the most part) who not to operate on.  How?  I had that discussion with @bonnycastle yesterday.  For me, I rely significantly on that *little voice*.  The voice that has been toned and taught and educated through 13 years of clinical practice.  The procedure does NOT end when the skin is closed.   We as surgeons must reflect upon the procedure, in the context of every patient, after the procedure, and at every follow up visit.  Did the procedure produce the intended result?  Was it a *success*?  If not, then why.  Could it be something particular to the patient… or is it simply the fact that there are no surgical procedures with a 100% *success* rate.  

If there are *complicating* patient variables—whatever they may be— the surgeon needs to recognize them, catalog them and be able to *recall* this in the future the next time they are faced with the same *type* of patient and a similar diagnosis.  This is not always a conscious decision or thought pattern.  Bonnie referred to this as—-

*Unconscious Competence*…  an automaticity pattern that allows experienced surgeons to jump from a-h without thinking about all the steps in between. 

How do we teach this?  Can a process which is occurring at a subconscious level be taught? 

Interested in your thoughts! 



About hjluks

A busy Academic Orthopedic Surgeon, Digital Strategist, Chief Medical Officer and father... intently and efficiently navigating the intersection of Social Media and Health Care.
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4 Responses to Unconscious Competence: Is the Procedure Over When the Skin is Closed? Or….

  1. Bonnycastle says:

    There are three important elements I would like to add 1. Competence is a cycle whereby learners continually move from unconscious incompetence to conscious incompetence to conscious competence to unconscious competence. 2. Making the implicit explicit is part of the job of teaching see http://blogs.usask.ca/medical_education/archive/2009/08/_making_the_imp.html and finally 3. Teaching med students to deliberately practice will provide lifelong benefits http://medicaleducation.wetpaint.com/page/Deliberately+Practicing.

  2. Bryan Vartabedian says:

    Perhaps we’re making some reference to clinical judgment here. This, of course, is very difficult to teach and comes from those 13 years of experience. Provocative post.

  3. coachkiki says:

    To use the analytic phrase “becoming conscious of the unconscious” would be a good tool for this kind of learning and knowledge. Learning how to identify and articulate “the little voice” in order to know what the information is, how to access it and how to use it.

  4. ravimohanv says:

    I think we are talking about “The power of thinking without thinking”-Blink (Malcom Gladwell).Eventhough 15 years of experience can’t be taught in 15 hours,the process can be expedited by encouraging reflective practice.We have regular labour ward refelection involving all the doctors with different level of experience.This helps a lot sharing experience and facilitating the learning process.We encourage the juniors to ask questions & to challenge our decisions.

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