Education and Training

Understanding the Dreyfus model of skill acquisition to improve

ultrasound training for obstetrics and gynaecology trainees

Alexander Field
Department of Women’s Health, Broomfield Hospital, Court Road, Chelmsford, Essex CM1 7ET, UK and the Department of Clinical
Education and Leadership, University of Bedfordshire, Luton, LU1 3JU, UK
Corresponding author: Alexander Field. Email: alexander.field@meht.nhs.uk

Abstract
There have been significant problems in ultrasound training since the introduction of the new postgraduate curriculum for
obstetrics and gynaecology. It is therefore important to understand how the skill of ultrasound is acquired in order to be
able to improve the training program. Here, the potential application of the Dreyfus model of skill acquisition has been
analysed to map the progression from novice to master and the progressions between each stage analysed. Although the
Dreyfus model is not a perfect match for ultrasound scanning, it provides us with a theoretical framework on which to
underpin educational practice in this field.

Keywords: Dreyfus, ultrasound training, obstetrics and gynaecology

Ultrasound 2014; 22: 118–122. DOI: 10.1177/1742271X14521125

Introduction to the problem trainees needing ultrasound training, too little cover in rotas
for them to be educated effectively, too few supervisors and
The introduction of the new Postgraduate Medical
too few resources.2
Education and Training Board–approved Royal College of
In practice, trainees may go months in between super-
Obstetricians and Gynaecologists (RCOG) curriculum
vised scanning sessions and have different supervisors each
involved major changes to ultrasound training for trainees.1
time. There is little provision for reducing the number of
Prior to these changes, basic ultrasound would be ‘infor- patients on an ultrasound list to allow time for teaching.
mally’ acquired during training and those wishing to This ad hoc approach to training leads to trainees with lim-
obtain formal qualification in more advanced skills could ited experience and confidence and does nothing to solve
undertake a diploma from the RCOG. With the introduction the problem of too few obstetricians and gynaecologists
of the new curriculum came an expectation that all trainees who can competently scan. The result is that ‘deanery deliv-
should be able to scan to a basic level, with optional inter- ery of ultrasound training is an ongoing issue’ as noted by
mediate modules for those wishing to undertake further the General Medical Council.3
training. Rather than a separate qualification, such as the It is clear that there is no magic solution to the current
previous diploma (involving dedicated, protected scanning problem.2 There will be few extra resources provided for
time), training is now integrated into the general obstetrics ultrasound training and no sudden increase in training
and gynaecology program much like any other skill (e.g. time or available supervisors. Therefore, it is imperative to
Caesarean section) with progress assessed by a compe- maximise the opportunities that are present and ensure that
tency-based logbook and work-based assessments.1 training is as efficient as possible to meet the goal of produ-
Unfortunately, this has led to ultrasound training becom- cing clinicians who are competent and confident in per-
ing one of the most contentious areas of the curriculum. forming basic ultrasonography. I propose that it is first
There is often little time in busy rotas to set aside for regular necessary to understand how trainees learn to scan and pro-
protected scanning sessions. In addition, many hospitals do gress from novice to master. To do this I will analyse the
not have consultants capable of supervising training, so the Dreyfus and Dreyfus model of skill acquisition applied to
burden falls upon ultrasonographers. There is a shortage of ultrasound training and examine some of its strengths and
qualified sonographers who not only have increasingly full weaknesses in this domain. I will then consider how this
scanning sessions but also their own students to teach. In theoretical underpinning may be used to influence educa-
short, there are now too many obstetrics and gynaecology tional practice.

Ultrasound 2014; 22: 118–122

 Field The Dreyfus model and ultrasound training 119
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The Dreyfus model of skill acquisition have low malignant potential based on ultrasound appear-
ances and experience and actively watched in a patient with
The Dreyfus model, first proposed in 1980, breaks down the
medical co-morbidities. As Caraccio et al.5 state, they ‘‘can
process of practical skill acquisition into five distinct stages.4
live with ambiguity’’.
The original model was subsequently adapted to the learn-
Although the proficient scanner by now has a large inter-
ing of clinical skills and the five stages widened to include a
nal library of experience, they still need to approach new
sixth. These stages are novice, advanced beginner, compe-
and complicated problems analytically. They remain aware
tent, proficient, expert and master.5 The original model cast
of their own limitations and are comfortable asking for
the description of the development of a practical skill as a
second opinions.
‘successive transformation of four mental functions’ from a
‘primitive’ to a ‘sophisticated’ form. Essentially, by develop-
The expert
ing sophisticated forms of recollection, recognition, decision
and awareness, it is possible to move from the rule-based The expert scanner can scan intuitively. They can tailor the
analytical novice engaged in active thought to the intuitive, scan according to the patient’s signs and symptoms and are
experience-driven master of a particular skill capable of happy to scan in a different order if required. For example,
other activities simultaneously.4 they are unconcerned by the foetus in an awkward position
whilst trying to do an anomaly scan and instead scan what
The Dreyfus model applied to they can and have acquired a variety of ‘tricks’ to get round
the problem. They are continuously adjusting the machine
clinical ultrasound settings whilst simultaneously scanning to always obtain
The novice the best possible images. Because they no longer need
Initially, the novice approaches every ultrasound examin- such active attention on what they are doing, they are
ation in the same fashion, with no flexibility for patient able to engage with other tasks. This might include recog-
signs or symptoms. Ultrasound findings are reported, nising the patient’s well-being or discomfort and being able
rather than interpreted, because there is no previous experi- to talk and reassure them or being able to teach a medical
ence to compare with, and are reported in isolation without student at the same time. Similarly, they can integrate the
clinical correlation, i.e. the scan is viewed in a non-situa- patient’s response into the clinical findings. For example,
tional way. the patient’s tender posterior vaginal fornix is noticed and
The novice has to actively think through every step of the combined with the finding of an ovarian cyst to suggest a
ultrasound examination. This includes: doing the scan in a diagnosis of endometriosis.
set sequence; having to consciously consider probe orienta-
tion in order to map the images on the screen to the patient The master
and actively considering how to optimise the images in The master scanner is an expert, capable of moments of
terms of power, focus and depth. Due to the level of con- genius, who scans completely intuitively and is able to get
centration required to do this, they are unable to perform crystal clear images where others have struggled, under-
tasks simultaneously, such as talk to and reassure the stands the machine and ultrasound principles completely
patient or observe the patient for signs of discomfort or and applies them practically without thought. He/she is the
pain. sonographer that others come to for a second and definitive
opinion and maintains complete integration of patient signs
The competent and symptoms and ultrasound images in real time with a
The competent scanner has sufficient experience and has therapeutic focus rather than diagnostic.
seen enough cases to be able to start interpreting the
images in terms of the situation, rather than simply describ- Applying the adapted Dreyfus model
ing what is on the screen. For example, an echogenic to training
adnexal mass medial to the left ovary becomes a left ectopic
As stated by Hobson,2 much of the supervision of trainees
pregnancy in the patient in early pregnancy with abdom-
in ultrasound has fallen on sonographers rather than con-
inal pain and vaginal bleeding. However, they do not have
sultants. There is, however, a clear difference between sono-
enough experience to interpret every case in this way and
graphers and clinicians that scan. Whereas the
therefore use a mixture of pattern recognition and analytical
responsibility of a sonographer is to try and provide a diag-
reasoning. They still approach every examination the same
nosis or at least a description of the problem, the ultimate
way in order ‘not to miss anything’ and with a similar level
role of the clinician is to not only diagnose the problem but
of active vigilance to a novice.
also manage it. Therefore, training in ultrasound for clin-
icians needs to reflect this different focus.
The proficient Having set out an adaptation of the Dreyfus model
The proficient scanner can now be more holistic in the rec- applied to ultrasound, it is now necessary to consider
ognition of clinical problems and is able to start interpreting how this might be used to improve training. The old
the images with a view to potential management. For exam- method of unsupervised trial and error is no longer accept-
ple an ovarian cyst with septations, which in an otherwise able and as Dreyfus and Dreyfus4 state, learning is much
well patient would be removed, can be confidently said to more efficient with the aid of an instructor. In an ideal
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training programme therefore, there would be an overall images, should be held for the benefit of the whole commu-
educational supervisor responsible for the training of the nity. This evolution from the acquisition of knowledge to
individual. The educational supervisor, by being aware of the participation in learning may be seen in terms of the
the stage in the adapted Dreyfus model that the learner is at, learning metaphors described by Sfard7 as a complemen-
may tailor the education and opportunities to allow the tary process.
individual to make efficient progress.4 It is at this stage that the learner must be encouraged to
see beyond the ultrasound scan and start to consider clinical
Novice to competence management as well. Learners should be enabled to follow
their patients through to the operating theatre to see the
The step from novice to competent scanner involves the
clinical correlation with their ultrasound findings. This
development of a personal library of experience.
helps to reinforce the sense of responsibility for patient
Therefore, the novice scanner needs to be allowed to scan
outcomes associated with their ultrasound scans and deci-
as many patients as practically possible to build this library.
sion-making. This is very similar to the sense of ‘emotional
At the initial stage, there is a role for simulation, particu-
buy-in’ referred to by Caraccio et al.5 that needs to occur at
larly when learning the skill of transvaginal ultrasound.
this stage in training.
Ideally, this would be taught and supervised by one educa-
Many of these learning structures may be difficult to
tor so that a consistent approach may be learned. Heer
build in a district general hospital with other rota pressures.
et al.6 showed that using a simulation system, medical stu-
The formation of an acute gynaecology team responsible for
dents with no experience could learn to undertake basic
admitting, scanning and ultimately operating on patients
transvaginal scanning and achieve results that are consist-
might form part of the solution.
ent with those obtained by experienced doctors. With the
set of rules acquired from practice on the simulator, the nov-
Proficiency to expert
ice must then step up to real patients. Initially, the novice
should be supervised by their educational supervisor in The shift is now from teaching to mentoring. At this stage
scanning sessions, with a limited number of patients, to the proficient scanner needs a mentor, someone that they
allow the learner the extra time that their scanning requires. can bounce ideas off of and who supports them as they
Informed consent is vital to allow the supervisor and lear- become intuitive practitioners. This stage probably takes
ner to feel comfortable exchanging real-time feedback. An the longest as again it is firmly rooted in continuous expos-
experienced sonographer in the room provides someone to ure to clinical cases and reflection afterwards. Caraccio
reassure the patient and notice if he/she is getting dis- et al.5 suggest that, at this stage, it is important that the
tressed, while the learner is absorbed in scanning. This learner is ‘‘not presented with complex unknowns’’ other-
experience can then be broadened to supervision by other wise they risk slipping back into analytical practice rather
supervisors to allow the learner to develop a range of than developing and trusting their intuition.
approaches.
A logbook of experience and work-based assessments Expert to master
should be completed to show progression and the end of
The expert ultrasonographer now needs interesting and
each scanning session should include a debrief and period
complex cases to keep them occupied and developing.
of reflection.
They should be encouraged to start providing second opin-
The next stage is to start unsupervised ultrasound scan-
ions to other clinicians and it may be that at this point they
ning. To ensure that the department and individual feel
start to become educators themselves. Similarly, the pro-
comfortable at this stage, a set of rules should be agreed
cesses of reflection and self-assessment must be developed
upon to ensure patient safety. This might include reviewing
to become a truly masterful practitioner.
the images with an expert after the scan, having a very low
threshold for rescanning the patient by someone with more
experience or limiting the type of patients who are scanned. Discussion
For example, scans may be limited to those who already While superficially it seems possible to map the Dreyfus
have confirmed intra-uterine pregnancies or those very model to ultrasound scanning, a number of important
unlikely to have ectopic pregnancies. issues arise.

Competence to proficiency Do ultrasound experts rely on intuition

As competency develops, restrictions on scanning may be and non-analytical problem-solving
relaxed, but with a clear expectation that a second opinion as much as the Dreyfus model suggests?
should be sought when the learner is unsure. The learner The answer, I would suggest, is probably not. As Pena8
should be present during second opinion scans and encour- discusses in his critique of the Dreyfus model applied to
aged to reflect afterwards to maximise the learning oppor- clinical problem solving, clinical experts must use both ana-
tunity. At this point, the learner should be integrating into lytical and non-analytical approaches concurrently.
the clinical team, e.g. the early pregnancy or gynaecology Intuition may suggest a diagnosis, but this is only the initial
oncology team and becoming a member of a learning com- step, as this provisional diagnosis must be considered
munity. Learning is now fundamentally by participation, rationally and proof sought in the form of investigations.
and weekly team meetings, with interesting cases and The two forms of reasoning are probably not mutually
 Field The Dreyfus model and ultrasound training 121
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exclusive and it is likely that both contribute to final deci- model’’. However, it is important to remember that the
sion-making. The expert may well be the person who can Dreyfus model was a model of ‘skill acquisition’ rather
use both forms efficiently rather than relying simply on than a model of skill assessment. In reality, there is a spec-
intuition.9 Similarly, in the field of ultrasound, it is hard to trum of learning, with the stages of the Dreyfus model
imagine even expert scanners scanning without question- being theoretical landmarks along the way. When assessing
ing their initial intuition of what they are scanning. It is also a particular skill, it is very hard to know when a learner has
worth casting a critical eye over the original Dreyfus model definitely reached each landmark. In addition, as Khan and
in this regard. The practical example the Dreyfus brothers Ramachandran discuss,10 performance is assessed by obser-
worked with was that of aviation, a field which more than vation, an act that can have an effect on the actual perform-
any other, forces even its experts to follow rigid procedures ance. They go on to suggest a performance rating scale
and checklists rather than simply trusting in the intuitive directly mapping stages in medical training to the
ability of pilots to fly. This is a form of ‘enforced’ regression Dreyfus stages. Ultrasound performance can be assessed
back to analytical reasoning. by direct observation and by use of simulators to explore
someone’s competence. These direct observations can be in
Does the model work when the aim of training the form of the standard work-based assessments and these
is not to produce ‘masters’ but simply competency? observations used to gauge competency. The actual per-
formance can be monitored by the use of image review
The original Dreyfus model involved an assumption that
and case-based discussions as well as actual feedback
all learners would aim to progress to master stage.
from the patients. Direct correlation between performance
However, the stated aim of the RCOG is to produce clin-
in a given task with the original Dreyfus model may be
icians competent to undertake basic ultrasound scans and
made using the Khan and Ramachandran performance
indeed the only compulsory modules are those entitled
rating scale.10
‘basic ultrasound modules’. In reality, it is probably suffi-
cient for learners to reach the ‘proficient’ stage in a limited
number of situations to meet this requirement. Combined What about changing clinical practice?
with the competency-based assessment model, there is a The problems with current ultrasound training are diverse
danger that learners will be deemed competent and and not easily solved. The Dreyfus model is based on the
allowed to practise independently but without the encour- development of a personal ‘library’ of experience and this
agement and drive to progress to the later stages of the can only come about with regular dedicated ultrasound
model. Rather than become active members of a learning scanning opportunities. Obviously, this involves making
community, using reflection and self-assessment to hone ultrasound training a priority and providing protected
their skills, learners become stuck at the proficient level, rota time and enthusiastic educational supervisors. There
able to undertake basic scans with reasonable confidence are preliminary studies that suggest that simulation may
but still having to refer the more interesting cases onwards. have a role to play, especially in the very first stages of
In reality, with the pressures on the delivery of ultrasound the Dreyfus model.11 These simulators allow practice
training, active input and supervision are likely to con- away from real patients at a time that is convenient for
tinue until the trainee has been ‘signed-off’ as competent, doctors with other clinical responsibilities. In addition,
at which point the learner will be left to fend for himself or many of the high fidelity simulators have very good clinical
herself. Potentially, if these learners continue scanning at correlation with real patients and so these cases can form
this level, they will eventually continue to progress part of the learner’s library of experience. However, access
through the model but ultimately only becoming ‘masters to these simulators is limited by the very high cost of
of the basic scan’. equipment.
Departments need to see the value of ensuring good
Is regression through the model possible? ultrasound training and using trainees effectively. Philips
and Rajasri12 report on a scheme at their local hospital
Another issue not addressed by Dreyfus and Dreyfus is
which sees a dedicated week of ultrasound training begin-
whether it is possible to regress in the model. In current
ning and ending with skills assessment. The supervisors in
reality with ad hoc training, it is quite possible that someone
the scanning sessions were specifically briefed regarding
who is working at competent level may go several months
the students’ needs and this allowed the students to pro-
before performing any more scans and therefore regress
gress over the course of the week. Once trainees have been
back to the novice stage, as they lose the level of intuitive-
deemed competent, they should be encouraged to continue
ness they had previous attained and struggle to remember
scanning. This may be by encouraging them to scan patients
the basic rules that they had been taught. The prevention of
when on call if possible and in a safe fashion or by having
this regression needs to be built into the training program to
ensure adequate progression, including when trainees semi-supervised scanning lists. Once this happens and trai-
rotate to a new department. nees become incorporated into part of the ‘ultrasound
team’, they will also enter the ‘learning community’ that
is essential for further progression through the Dreyfus
What about assessment in the Dreyfus model? stages. Hopefully, much of this development of ultrasound
As Caraccio et al.5 point out, ‘‘many educators have skills will also coincide with development of other obstetric
adopted the assessment rubric of the Dreyfus and Dreyfus and gynaecology skills. For example, learning to scan
122 Ultrasound Volume 22 May 2014
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ectopic pregnancies concurrently with learning to remove 2. Hobson K. RCOG recommendations for trainee obstetricians and
them laparoscopically is potentially very beneficial for both gynaecologists. Ultrasound 2010;18:211
3. General Medical Council Annual Specialty Report for 2010/11 London:
skills.
GMC, 2011. See http://www.gmc-uk.org/RCOG_ASR.pdf_48273199.
pdf (last checked 7 July 2013)
Conclusions 4. Dreyfus S, Dreyfus H. A Five-Stage Model of the Mental Activities Involved
in Directed Skill Acquisition. University of California, Berkeley, US,
It is possible to map the Dreyfus and Dreyfus model of skill Operations Research Centre, 1980. See http://www.dtic.mil/cgi-bin/
acquisition to the specific skill of ultrasound scanning in GetTRDoc?AD¼ADA084551&Location¼U2&doc¼GetTRDoc.pdf (last
obstetrics and gynaecology. By doing so we can begin to checked 7 July 2013)
understand the stages a novice might go through to achieve 5. Caraccio C, Benson B, Nixon J, Derstine P. From the educational bench
to the clinical bedside: translating the Dreyfus Developmental Model to
mastery, and from this, how learners passing through these
the learning of clinical skills. Acad Med 2008;83:761–7
stages might be helped to make adequate progression. 6. Heer I, Middendorf K, Muller-Egloff S, Dugas M, Strauss A. Ultrasound
Given the very real time and resource pressures that limit training: the virtual patient. Ultrasound Obst Gynecol 2004;24:440–4
ultrasound training, this understanding can ensure that 7. Sfard A. On two metaphors for learning and the dangers of choosing
most efficient use is made of these opportunities. The just one. Edu Res 1998;27: 4–13
adapted Dreyfus model of skill acquisition is not a perfect 8. Pena A. The Dreyfus Model of Clinical Problem-Solving Skills Acquisition: A
Critical Perspective. Medical Education Online 2010;15:4846. Coaction
model for ultrasound scanning because of its overemphasis
Publishing [online]. See http://med-ed-online.net/index.php/meo
on intuitive rather than analytical problem solving and it (last checked 7 July 2013)
remains to be seen of how much practical use this model 9. Eva K. What every teacher needs to know about clinical reasoning. Med
will be when it comes to influencing actual practice. Edu 2004;39:98–106
10. Khan K, Ramachandran S. Conceptual framework for performance
assessment: competency, competence and performance in the context of
DECLARATIONS assessments in healthcare – deciphering the terminology. Med Teacher
The author has no conflicts of interest to declare. 2012;34:920–8
11. Nitsche J, Brost B. Obstetric ultrasound simulation. Semin Perinatol
2013;37:199–204
REFERENCES 12. Philips A, Rajasri A. Focused ultrasound training for specialty regis-
trars: a simple solution to curriculum difficulties. Arch Dis Childhood.
1. Roberts M, Hughes T. Who should perform the ultrasound examinations Fetal Neonat Ed 2011;96(suppl 1): fa138
in gynaecology? Obstet Gynaecol 2012;14:237–42