Articles and Case Studies

Unconscious Incompetence

27 Mar 2017

by Dr Paul Nisselle


How do I know that I don’t know what I ought to know? I won't know until someone in the know tells me!

The path to "unconscious competence"

When I started in general practice, there was no prescription writing software. When it became available later, there was a slow uptake. The fact that I was not competent to use it was irrelevant as my practice did not adopt it. My lack of that skill represented “unconscious incompetence”.

I have returned to GP work in a highly computerised practice. My sweaty palms were physical evidence of “conscious incompetence”. The practice manager rolled her eyes and gave me a thorough tutorial. A short time later, I would be back in the consulting room trying to remember all I had been taught, struggling for “conscious competence”. Over time, using it became automatic – I now exhibit “unconscious competence”.

Adult learning starts with discomfort

It's the unsettling feeling of conscious incompetence when you can’t make a diagnosis or don’t know how to treat a patient. Or the patient may exhibit a behaviour you don’t know how to manage, e.g. extreme anger, extreme despair or just starting to cry. One response is to withdraw by removing the need. If a patient starts to cry, do you ignore their tears and just push on? Or do you say nothing but pass them a box of tissues to acknowledge you’ve seen their distress? Or do you verbalise that by saying something like, “I can see how distressing this has been for you, but do go on…”?

“Emotional” patients tip you from your comfort zone of clinical conscious or unconscious competence to a new feeling of conscious incompetence in managing the emotion, whether it’s distress at a life event or perhaps anger at you for some perceived act or omission of yours. You can learn how to manage such situations, but there’s the challenge of putting the work into becoming consciously competent and then spending the time practising to become unconsciously competent.

Going down the wrong path

Sometimes doctors take the wrong path from incompetence to competence. A General Surgeon with a poor litigation and complaints history might think the way to reduce their medico-legal risk is to do the next 100 or 500 cholecystectomies a bit slower and work on reducing their complication rate. However, some of those had the same complication rates as their peers but are sued more often – because the primary thread of the complaints they had received was dissatisfaction with their professional demeanour and behaviour, with the technical errors just the final precipitating factors.

So if you get that unsettling feeling of conscious incompetence, have the courage to talk about it with your registrar, your supervisor or your mentor. They will help you make an accurate diagnosis of what’s wrong, if indeed anything is.

The most dangerous stage, to patients, is a doctor’s unconscious incompetence. Fortunately, in hospitals, many people will be looking over your shoulder. But that’s a safety net with holes in it. Don’t be scared to ask yourself, “Am I really sure that’s the right diagnosis or treatment?” You need a strong ego to be a doctor, but you also need humility to be aware of your frailties. If someone’s not looking over your shoulder, find someone who will.

Shakespeare said it best: “This above all, to thine own self be true.”

You’re the only person in the world who really knows your weak points. Don’t be scared of "conscious incompetence", it’s the first step towards competence!

Dr Paul Nisselle AM
General Practitioner
Mutual Board Member, MDA National

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