Dinesh Palipana The competency matrix and use of reflection and reflective practice to develop your learning and understanding Stuart Lane

The Competency Matrix and the Use of Reflection and Reflective Practice to Develop your Learning and Understanding.

A/Prof Stuart Lane MBBS PhD FCICM MQHR Coordinator of Clinical Studies & Chair of the Personal and Professional Development (PPD) Theme, Sydney Medical Program; Senior Staff Specialist in Intensive Care Medicine, Nepean Hospital

A/Prof Stuart Lane is coordinator of Clinical Studies, and chair of the PPD theme for the Sydney Medical Program. He has a decorated record for teaching, and has developed a national and international reputation in researching human experience using qualitative methodologies. His PhD thesis explored the experiences of medical interns who had been involved in open disclosure. He is an examiner for the College of Intensive Care Medicine (CICM), Senior NSW CICM Supervisor of training, and Deputy Chair of the NSW CICM Regional Committee. He is a keen swimmer and successfully swam the English Channel in 2017.

Introduction

In the most recent edition of AMSJ I discussed the concepts of intellectual humility, growth mindset, and situational awareness, and their roles in the development of a person’s professionalism and professional identity. In this edition of AMSJ I will discuss some theories of reflection and reflective practice, which are required to utilise the concepts previously discussed, and enable the optimal development of your learning and professional development. In doing this I will discuss the competency matrix, which is a learning development theory that is referred to frequently in healthcare learning, especially in the context of simulated learning environments. I will also discuss some of the flaws in the current theory that are preventing the recognition of optimal reflective practice.

The competency matrix

The ability or inability to recognise one’s limitations, and therefore subsequent learning, is described in a learning framework called ‘the competency matrix’, which relates to the learning of a new skill, behaviour, ability, or technique [1] . The framework is outlined in Figure 1 below:

Learners begin at stage 1: ‘unconscious incompetence’. As their skills increase they enter stage 2 of ‘conscious incompetence’. With greater skill acquisition, they attain stage 3 of ‘conscious competence’. Finally, as they master their skill, they attain stage 4 of ‘unconscious competence’. This framework has a vitally important aspect. When students learn, they commonly wish to know how their learning is progressing, and this is often done by form of assessment [3] . Awarding students marks or grades, such as 7/10 or 56%, does not give the learner any indication of what they actually need to do to improve their score if they were to do the assessment again. This is the basis of the newer paradigms of assessment such as programmatic assessment [4] , which many medical schools are developing and implementing into their new curriculums. This narrative feedback encourages students to not simply settle for a ‘pass mark’, but develop a desire to reflect on performance and improve. Therefore, the ability of a learner to move through this matrix requires an ability to recognise which part of the matrix they are situated currently. Stages 2 and 3 are usually very obvious to learners, however stages 1 and 4 are not. Furthermore, having two distinct ends to learning suggests that there is a very obvious beginning and end, which is far too simple.

Figure 1. The conscious competency learning matrix – the four stages of learning [2].

Consider this model with a person learning to drive a car. Before learning to drive, many people have been in a car and sense that driving might be relatively easy to do. This is stage 1, where they are not aware of how difficult it can be for the person who has never done it before. When they actually have their first lessons, they realise how difficult it is and become aware of how unskilled they are, realising that they have a lot to learn. This is stage 2. As they continue to learn to drive, every step is very deliberate and thought out; however, they begin to gain competency and recognise the things that they are doing right. This is stage 3. Finally, they get to a point where driving is no longer deliberately thought-out; they can change gear and brake automatically without thinking. They are at stage 4, and no longer aware of their own competence. However, if the person ages and loses reflexes and abilities, this level of skill will change, or even if they simply change cars and become unfamiliar with their environment.

Figure 2. Level of learning and the competency matrix Learning can also be displayed in a time cycle, with time spent learning on the x-axis, and level of learning on the y-axis, as seen below in Figure 2. This model displays the ‘dip’ that people describe as they attempt to acquire a new skill. The ‘dip’ actually reflects a person’s appreciation of what they know, and therefore relates to their confidence rather than their knowledge.

The lack of focus on reflection and ongoing learning in this early model of the competency matrix is one of the significant flaws. Stage 4 ‘unconscious competence’ has also been described as ‘mastery’ [5] . This phrase suggests that the learner can learn no more: they have mastered their skill. This has obvious risks in the field of medicine, where disease concepts and knowledge, investigations, and management are continually changing. If a practitioner does not maintain their level of skill, they will no longer have ‘mastery’ of their subject. This can easily occur if apathy or complacency start to creep into a doctor’s practice [6] . This suggests that reflective practice is required if a practitioner is to maintain their mastery. However, as stated in the previous paragraph, the practitioner needs to reflect at both ends of the matrix (stage 1 and 4), as well as throughout the middle stages of 2 and 3. Reflective practice needs to be an ongoing process throughout a practitioner’s career; always present in the background or even the forefront of their thinking. This idea led to the development of a more recent version of the

matrix, displayed in figure 3.

Figure 3. Reflective competence as a fifth level of the competency matrix.

(Courtesy of Will Taylor, Chair, Department of Homeopathic Medicine, National College of Natural Medicine, Portland, Oregon, USA, March 2007 [6] ) Regarding teaching and learning, this fifth stage of competence has been described as ‘conscious competence of unconscious competence’, which is a person’s ability to recognise and develop unconscious incompetence in others and themselves [6] . More simply, it is described as reflective competence, as seen in Figure 3. The ability to recognise one’s ongoing learning needs, and the accumulation of one’s knowledge and application of said knowledge is a major aspect of emotional intelligence, and to recognise it in others is an even greater level of emotional intelligence.

The link between this article and my two previous articles can be seen here, where emotional intelligence for personal learning and the learning of others is intertwined with situational awareness (within the learning environment) and intellectual humility (in your rate of acquisition of knowledge versus what there is still to learn). Having learned a skill, many learners will forget what they went through to learn it, and how they mastered it – they have forgotten the theory and application and have become simply functional. This has a major impact if they try to teach the skill to somebody, as they will struggle to impart the knowledge if they can’t recall how they amassed it. Therefore, they can make worse teachers than someone who has good ability at the conscious competence stage [7] .

There are three other key aspects of learning that are neither demonstrated nor explained by this framework. Firstly, whilst the diagram demonstrates an overlap between each of the stages of the competency model, as stated earlier, reflective competence should occur at all stages. In some circumstances learners are not always ‘unconsciously incompetent’ from the beginning, and accept that they don’t know what they are attempting to learn, so they are ‘consciously incompetent’ from the beginning. However, in other clinical circumstances they are ‘unconsciously incompetent’, suggesting that their place on the competency matrix has to be related to the context of what they are learning. Therefore, the diagram relates to a specific person learning a specific task. This problem has commonly been related to younger learners, which can be derogatory as they may well be more willing to accept that they have a lot to learn, compared with a more experienced learner who might believe they can’t be taught anything new. Secondly, in some cases where the learner is at a level of being ‘consciously competent’, they become ‘unconsciously incompetent’ as further learning is attempted. This is related to the previously mentioned intellectual humility, and aligns with overconfidence as somebody acquires a new skill. Reflective competence should not be considered a fifth stage that occurs once a leaner has attained ‘unconscious competence’, but rather a background quality that is always present. Thirdly, whilst the initial diagram talks about learners going back from stage 4 to stage 3 and then stage 2, this only occurs if the person possesses reflective competence. If they do not possess this quality, they can regress from stage 4 of ‘unconscious competence’ directly to stage 1 of ‘unconscious incompetence’ without even realising. The current diagram does not show a link between unconscious competence and unconscious incompetence for when reflective competence is lost, and this process may occur. The point at which the transition from unconscious incompetence to conscious competence occurs has often been called the ‘light-bulb moment’ [8] , but the light-bulb might not flash in the opposite direction, going from unconscious competence to unconscious incompetence if the learner doesn’t possess reflective competence.

What this learning model demonstrates is that whether or not a learner is actually ready to learn may not be so straightforward. The ability to possess the correct mindset to learn links with the previous discussion regarding intellectual humility and situational awareness. Whereas a growth mindset is about how you apply oneself to the learning environment once you are immersed in it, the competency matrix, and especially the beginning of the matrix, influences your ability to learn before you have even entered the learning environment. Since mentors and educators are not always present in a learner’s development, it is imperative that they impart the ability and the desire for the learner to develop and sustain reflective competence throughout their learning. If learners have the intellectual ability, a desire to learn, and also possesses reflective competence, then they should eventually develop unconscious competence – mastery. If learners start to learn, but become overconfident in their learning and their abilities, they have lost the ability of reflective competence and will once again be unconsciously incompetent. If learners develop ‘mastery’ of the process and they maintain reflective competence, they will recognise when they are beginning to lose or have lost their ‘mastery’, meaning they can choose to reharness their skills or not to. Therefore, the important aspect for learners and educators is not just ensuring how learners negotiate the competency framework, but how they are cognitively situated before they commence the learning process, and how they will remain cognitively situated throughout their ongoing learning.

Conclusion

This is the final instalment in the series of discussions around your professional identity and the development of your learning and professional practice. What I hope I have demonstrated is that a huge amount of responsibility for ongoing learning and development rests with the learner themselves, and not with assessment organisations and accreditation bodies. It is useful to know about theory and concepts such as the competency matrix, intellectual humility, growth mindset, and situational awareness, however the most important aspect is how you personally utilise these theories and develop them within your own learning and professional practice.

Your medical career can be long, and within that time your ability to learn and perform will inevitably change, and not always for the better. Therefore, it is vital that you recognise that your learning is there to help others – your patients. Your patients are the ultimate beneficiary of your learning and development, which is why it is paramount that you start to ensure it develops optimally as early as you can in your career. This requires reflecting with the right people at the right time in the right manner, including yourself.

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[8] References

Conger DS, Mullen D. Life skills. Int J Adv Counsell. 1981;4(4):305-319. Peck M. Blog of an Auckland Magician [Internet]. Auckland, New Zealand: Peck M. 2011 - . The Four Stages of Learning; 2013 Aug 22. Available from: http://aucklandmagicianblog. com/the-four-stages-of-learning/ Wormald BW, Schoeman S, Somasunderam A, Penn M. Assessment drives learning: an unavoidable truth? Anat Sci Educ. 2009;2(5):199-204. van der Vleuten CP, Schuwirth LW, Driessen EW, Dijkstra J, et al. A model for programmatic assessment fit for purpose. Med Teach. 2012;34(3):205-214. Barrett LF, Russell JA. The structure of current affect: controversies and emerging consensus. Curr Directions Psychol Sci. 1999;8(1):10-14. Businessballs [Internet]. England: Businessballs; 2019. Conscious Competence Learning Model; [cited 2019 Oct]. Available from: https://www.businessballs.com/ self-awareness/conscious-competence-learning-model/ Nonaka I. A Dynamic Theory of Organizational Knowledge Creation. Organization Sci. 1994;5(1):14-37. Oxford Dictionaries [Internet]. England: Oxford University Press; c2019. Light-Bulb Moment. Available from: http://www. oxforddictionaries.com/definition/english/light-bulb-moment

An Interview with Professor Alicia Jenkins – Endocrinologist, Researcher and President of Insulin for Life

David Chen Bachelor of Medicine/Bachelor of Surgery (Honours) 5th year medical student (5-year degree) at Monash University David is a final year medical student at Monash University and an Associate Editor of the Australian Medical Student Journal. He has undertaken research projects in diabetes, which he has greatly enjoyed.

Prof. Alicia Jenkins MBBS, MD, FRACP, FRCP Director of Diabetes and Vascular Medicine at NHMRC Clinical Trials Centre Prof. Jenkins is a clinician-scientist with interests in diabetes and vascular medicine working at NHMRC Clinical Trials Centre and St Vincent’s Hospital Melbourne. She is also the President of Insulin for Life.

In this issue of the Australian Medical Student Journal, we are fortunate to interview Professor Alicia Jenkins, a Clinical Endocrinologist at St Vincent’s Hospital Melbourne, Director of Diabetes and Vascular Medicine at NHMRC Clinical Trials Centre and President of Insulin for Life. She was also recently awarded the prestigious ADS Kellion Award, which acknowledges an outstanding contribution to diabetes research, clinical or service areas. Prof. Jenkins provides us with an insight into the field of diabetes and endocrinology, the benefits of undertaking research, as well as her charity work for Insulin for Life.

Prof. Alicia Jenkins

Q: Why did you become a doctor? A: “To help people”. This is the answer I gave as a 17 year old, who grew up in a farming community when asked after having been offered a place in medicine at the University of Melbourne. It’s still the same reason I continue long hours as a clinician, medical researcher, educator and advocate.

It’s a diverse, challenging, rewarding, achievable and incredibly important goal.

Q: Why did you choose a career in endocrinology? A: My mother was diagnosed with Type 1 diabetes in 1939 (and lived until age 92), so I knew the challenges that people with diabetes face, and the importance of excellent and accessible care and of research. I was interested in all aspects of medicine during medical school and residency, and as diabetes is common and impacts every system in the body endocrinology was a great fit for me.

An added bonus was the strong laboratory and research options that can improve patient outcomes.

Q: How would you describe the typical day of an endocrinologist? A: The typical day for most endocrinologists is providing specialist care to people with diabetes, or other conditions affecting other hormone systems, such as the thyroid, pituitary, adrenal, bone or reproductive organs. Most of this is done on an outpatient basis, with some inpatient work for some.

The endocrinologist will interact with patients and often with their family, other general and specialist clinicians and allied healthcare providers. Some time should be spent in ongoing education, such as reading medical journals, as treatment options for endocrine conditions are advancing rapidly and it’s important to be up to date so as to provide the best care. An endocrinologist involved in research and teaching will also need to spend time writing research grants, conducting funded research, which may be people and/or laboratory based, and in training activities.

Q: What do you find most rewarding about your work? A: Making a positive impact in the lives of many people, including patients and their families, other healthcare professionals, trainees and researchers. The diverse range of skillsets and work-place options (clinic, university, research laboratory, national and international work places) add to it.

Q: What advice would you give to medical students and doctors interested in a careerin endocrinology? A: Endocrinology has so many career options within: subspecialties, a mixture of clinical, research and teaching; part-time or full-time and diverse (urban, rural, remote or overseas) work locations.

And with the diabetes epidemic there is certainly job security! It’s great if you like caring for individuals long-term, being part of a multi-disciplinary team, and are interested in evidence-based medicine with new drugs and devices.

Q: How did you become interested in research and what is the current focus of your research? A: As a registrar I was exposed to a research active endocrinology unit at the University of Melbourne (St. Vincent’s Hospital) and realised that existent treatments and care delivery could be expanded so as to improve health outcomes for people with or at risk of diabetes. My research focus is the prediction and prevention of diabetes complications via the optimal use of technology (e.g. pumps, sensors, telemedicine), and (clinical, biochemical and molecular) biomarkers. This involves conducting clinical trials of new and repurposed drugs and devices.

Q: What are the benefits of being exposed to research as a medical student? A: There are many benefits, and of course some challenges. Research trains one in analytical thinking, in accessing and assessing evidence and in communicating ‘science’ and the gaps in medical science and care to others (including medical, scientific and lay groups). Every good doctor, even if they don’t do any research or continue in research, will utilise research results in their daily clinical practice.

Q: Could you tell us about your charity, Insulin for Life (IFL)? A: IFL (www.insulinforlife.org) collects in-date unopened diabetes supplies in (so far nine) affluent countries and provides them at no cost to clinics for the poor in over 40 disadvantaged countries.

We help run (overseas) diabetes camps, community screening days, with advocacy and global health research. Seventy-five percent of the people with diabetes in the world today live in disad vantaged regions, and I believe it is important that those of us who have the capacity to help others should do so. Health is wealth and as medical students and doctors with expertise in health, we have much to share.

Q: How can medical students and doctors contribute to this excellent cause? A: There are many options. Diverse skill-sets and time commitments are welcome. Volunteers can help raise awareness, fundraise, help with camps, prepare diabetes supply shipments (going from

Ballarat), help with social media, website monitoring and research projects.

Check out www.insulinforlife.org or contact me (alicia.jenkins@ctc.usyd.edu.au).

Correspondence David Chen dchen092@gmail.com