Unconscious Competence: Viviendo la vida locums

January 6th, 2012 by Kenneth Cohn

I apologize for the delay in posting.  Although I looked forward to taking a holiday vacation, I have come to the aid of a surgical colleague at a critical access hospital in New England who had no backup. I enjoy being of service and being thought of as a solution rather than the problem.

Last weekend, I was asked to consult on a patient who fell and had a 10% pneumothorax (a small air leak in the lung into the chest cavity).  Usually, the air appears on the lateral (outside) surface of the lung, but this time it was medial, a finding that I had never seen before.  I shared my lack of certainty with the patient and encouraged her to be transferred to the tertiary hospital where they had interventional radiologists on call who could guide her treatment.

I learned later that the medial air collection was due to the lateral lung being stuck to the chest from a previous injury or inflammatory process and that a chest tube placed via the (traditional) lateral approach would likely injure the adherent lung and not evacuate the pneumothorax. 

My grandmother called these episodes her “once-in-a-whilers.”  May we all be so fortunate to have as many “once-in-a-whilers”  as she did during her 95 years.  A talented,  intuitive general surgeon commented when I did something right, “Ken, the Good Lord, she was surely watching over you.”  A cardiac surgeon quipped, “It just goes to show that even the blindest sow finds and acorn now and again.”

During residency, I learned about the journey through the four stages of competence:

  • Unconscious incompetence: people make mistakes because they are unaware that they are missing information (e.g. the July 1 house officer transition)
  • Conscious incompetence: usually following unconscious incompetence, they feel upset and embarrassed and question their knowledge
  • Conscious competence: over time, they feel more comfortable about their skills, knowledge, and judgment
  • Unconscious competence: they trust their instincts and allow those instincts to influence their decision-making, especially when something “just doesn’t feel right.”

Donald Schoen described unconscious competence as reflection in action, a series of course corrections that experienced practitioners make, often without realizing that they are making them until they are asked to think aloud by a student or resident who is shadowing them.  Whatever the explanation, I feel fortunate to work in a profession where I am allowed, and occasionally encouraged, to trust my gut.

As always, I welcome your input to improve healthcare collaboration where you work.

Kenneth H. Cohn

© 2012, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

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