Each and every skill we possess falls into one of the following 5 categories of proficiency...
(1) In the novice stage, the freshman medical student begins to learn the process of taking a history and memorizes the elements, chief complaint, history of the present illness, review of systems, and family and social history.
(2) In the advanced beginner stage, the junior medical student begins to see aspects of common situations, such as those facing hospitalized patients (admission, rounds, discharge) that cannot be defined objectively apart from concrete situations and can only be learned through experience. Maxims emerge from that experience to guide the learner.
(3) In the competent stage, the resident physician learns to plan the approach to each patient’s situation. Risks are involved, but supervisory practices are put in place to protect the patient. Because the resident has planned the care, the consequences of the plan are knowable to the resident and offer the resident an opportunity to learn.
(4) In the proficient stage, the specialist physician early in practice struggles with developing routines that can streamline the approach to the patient. Managing the multiple distracting stimuli in a thoughtful way is intellectually and emotionally absorbing.
(5) In the expert stage, the mid-career physician has learned to recognize patterns of discrete clues and to move quickly, using what he or she might call "intuition" to do the work. The physician is attuned to distortions in patterns or to slow down when things "don’t fit" the expected pattern.
