Having difficulty maintaining your general practice skills, and/or having difficulty completing assessment requirements?

We do become more set in our ways as we become older and wiser.   Most of the time this is an advantage, but not when completing GP Assessments.

It is well documented in the literature that the following factors negatively influence GP assessment performance:

  • Older doctors (Age >35 years);
  • More experienced docs;
  • Docs that have been working in a specialised GP environment; and
  • Docs that have previously worked in another medical speciality.

So why is this?   

Exams measure the Science of Medicine, not the Art.

The Stages of Learning

Let’s look at the stages of learning to understand the problem:

Stages of learning


  • In medical schoolyou don’t know what you don’t know – that’s why you cannot work independently – and have a hierarchy of senior clinicians to provide guidance as to what you should know.
  • In intern and early hospital years – you are aware of what you need to learn (conscious incompetence), and actively seek guidance as to how to achieve this.
  • In vocational training years – you are still consciously incompetent, but have other cues on which to make clinical decisions, and have gained more experience to inform your contextual knowledge.  Importantly, you know when to ask for help.
  • Around the time of Fellowship – you should have achieved conscious competence – still inexperienced and need to think through things, but confident in the process, and able to reflect to improve your knowledge.  If you have completed your primary medical qualification in Australia and entered GP training in PGY3 or 4 which is usual, you are still quite inexperienced in your medical career.  The literature reports that it takes 10,000 hours to be an expert.   If you’re a newly graduated doctor working a 40 hour week, 52 weeks a year, you won’t be an ‘expert’ in your current skills until you are 5 years post-graduate (if you never have a holiday).
  • Post-Fellowship – you demonstrate unconscious competence – you can practice without thinking, based on your clinical knowledge and the ‘illness scripts’ and patient experiences that you have encountered over time.

For those of you that are Gen Z than I, here’s an Emoji version.

graph competence.PNG


But what if you have developed unconscious competence before your commence your training in General Practice?   If you are thinking an an ‘automated way’, this can impact upon the way that you approach both your practice and assessment processes.

We know that ‘experienced clinicians’ or ‘experts’ mainly use pattern recognition to make a diagnosis, but when they encounter a difficult case, can reflexively move to hypothetico-deductive reasoning to find a solution.  There is a difference between recognising a pattern and affirming it, and proposing a hypothesis and disputing it – that’s the safety element that’s tested in exams.    If you’re unfamiliar with these concepts, here’s a great blog that will help explain.

GP Exams test your ability to move between these two processes as that is the skill required for safe and independent practice.  Most experienced clinicians move between pattern recognition and using deductive reasoning by ‘gut feel’ – what the patient is telling them doesn’t reflect what the patient looks like, or what the doctor know about the patient – but in the exams we are diagnosing in a vacuum, so we need other cues to inform our thinking.

If you’re stuck comfortably in Stage 4 or incompetence competence, your ‘leopard spots’ have been there for some time.   The spots are difficult to change, but the way you, or others view them, can be.

The Fifth Stage of Learning

Theorists have proposed a fifth stage of learning, Reflective Competence.  Unconscious competence can lead to complacency and a false sense of expertise.  The learning pyramid is not static.  We work up and down the pyramid depending on what environment, patient demographic and diagnostic dilemma we are facing.   It is suggested that mastery requires at least two passes through the whole pyramid  and without Reflective competence that cannot be achieved.   That’s why Professional Development Programs are so important.

Even if we develop unconscious competence, it is proposed that 20% of our practice remains unknown, and that 20% is not fixed.  Reference. Given the nature of medicine, should ever be comfortable being unconsciously competent?

I propose that Stage 5 should actually sit between Stages 2 and 3.

So how do we Unthink our Thinking and Change our Spots?

This is a great quote that rings true for clinical reasoning in medicine:

“You are what you say, but what you say depends on what you feel/think/know, and what you feel/think/know depends on what you have learned so far.”     


If you approach the GP exams in the above manner, likely due to being an experienced clinician, it is likely that you will pattern recognise the answers and fail to demonstrate the clinical reasoning processes that are required to pass.

The key is being willing to be a beginner again – at any time in your medical career, but most importantly if you are having difficulty passing assessments.                        Reference

I do like this analogy of a ladder (there are way too many pyramids in education).  ladder



Just because you can reach the ceiling using the ladder, doesn’t mean that it is the safest, most efficient, or cost-effective way to get there.


Perhaps we should move away from triangles and pyramids in education theory?


Here is a beautiful model based on a ‘spot’.    Unfortunately, many of our assessment and education programs focus too much Miller’s pyramid and not enough on how we transition from one level to the next.

Reflective competence should be paramount as acquisition of that skill is required for transition through all others.

spot model


Leopards can change how their spots are interpreted.

If your spots are amenable to jungle camouflage (your routine practice) then that’s OK,  but you also need to learn to adapt to any environment in which you inhabit (i.e. the exams).

You can change (the perception of) your spots by:

  1. Acknowledging that you have a problem;
  2. Defining the environs in which you inhabit;
  3. Identifying the strengths in your clinical knowledge and practice;
  4. Identifying the clinical knowledge areas that you can improve upon;
  5. Identifying the biases that influence the way you make clinical decisions;
  6. Engaging the help of a colleague to ensure that you have appropriately reflected.

If you need a hand, an Assessment in Medicine Consultation might be helpful.  Leopards can live in desserts, forests, mountains, grasslands and deserts, but their spots may not suit all of those environs.

They are likely to thrive with some advice about why and how they will best adapt.








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