Tuesday, 26 August 2014

QuizUp and the dangers of Unconscious Competence

I have recently been playing QuizUp. It is an online quiz which you can play real time against other people from all parts of the world. There are innumerable topics and categories with thousands of people playing it.

I chose a topic that was familiar and another one which was not familiar. What I learned was something many of us may already know. But are we applying what we already know? Are we harming people by not recognising and applying what we know in a proper manner?

When I start playing QuizUp even for very familiar topics such as medicine or healthcare I had to read the questions slowly because the style and format of the question is different for each question. Some are direct, some are linked with directly topic related pictures, some are related with general pictures from news and social media that relate to the topic, some have humour, others have pun and so on. Then comes the answers there are very technical answers from some questions, lay answers for some, humorous answers for others and so on. So even when I understood the question perfectly well and knew AN answer which was right, THE answer that was right for QuizUp took time to learn. Of course there is the issue of learning the answers that I did not know before. 

Now, once these were learned, the issue became one of speed, because even if I knew all the answers if I did not answer them fast enough I would lose. At this point, I began winning a number of matches/plays/games. But also loosing a number of them because the speed itself caused errors due to many reasons including the jumbling of answers and the pressure involved in a fast recall and response to a touch screen.

At this stage, there is enough knowledge, memory, recall and speed which then moves on to pattern recognition. Most often there was no need to read the questions or the answers the responses came automatically, fast and correctly. It was on auto-pilot and very successful.

My scores were soaring, the whole thing was getting a bit monotonous, repetitive and pointless. This is when QuizUp decided to update the questions so there were a number of new questions thrown in. Obviously I had to go through the sequence described above for these new questions. That is when I discovered that I not only had trouble with the new questions in terms of knowledge, speed etc. Because the new questions had been interspersed with the older/original ones I was struggling with the older ones as well.

I was struggling to answer questions that I used to answer automatically and correctly within a second. I was getting them either slow or wrong. I was UK top ten for a particular month in the topic and was getting stuff wrong. Interestingly, because I was already way up top ten it really did not matter, I did not drop too many ranks if at all. Mind you, I am talking about marginal differences here. The nature of the game and my overall rank meant I was still winning but not as efficiently as before.

The worrying thing was that the minute I stopped pattern matching my scores fell.

The last point I wish to draw your attention to is this. I was concerned about the efficiency of my wins and started reviewing my questions by reading the question and answer in detail after playing each game. I was surprised that I was neither fully aware of the wordings of the question nor the logic of the answers; I knew what the question was and what the answer was that is knowledge but while answering them repeatedly my knowledge formed the basis of pattern matching but as the pattern matching became dominant potential and/or real drops in awareness of knowledge and on some occasions of knowledge itself happened.

Pondering on the above gave rise to some worrying thoughts and certain concepts which may be negatively affecting some of us.

Many of you with some knowledge about education and learning methods will recognise the model where we are

Unconsciously incompetent

Consciously incompetent

Consciously competent

Unconsciously competent

These are called the four stages of learning or four stages of competence and linked with the concepts around the Johari window.

Is there a risk with Unconscious Competence?

You would have noticed from my above description that like any learning or skill my QuizUp journey moved from Unconsciously Incompetent to Unconsciously Comptent. Educationalists and trainers want us to be unconsciously competent, it is supposed to be the highest in the hierarchy of learning and competence.

Here is the worry or the risk.

Many senior experienced older doctors are unconsciously competent, i.e. where we actually want them to be. When we want them to incorporate something new into their routines we are pushing them back to conscious competence. We are aware for that for the new skill there is a learning curve, we accept that. I am not sure if whether while the new skill is being incorporated their performance with their established skills fall, even temporarily; and if it were to fall whether we even notice it as it is likely to be subsumed in the averages of their overall numbers/performance which had a good baseline to start with.

But, here is the more worrying aspect. Due to some unfortunate reason if any of the senior established busy doctors were referred for an assessment of their knowledge and competence (say to an agency such as NCAS) these doctors are tested for their conscious competence when their daily practice is in the domain of unconscious competence. Add the pressure and stress of going through the formal assessments that decide the fate of their careers, these doctors often unsurprisingly come out as lacking in knowledge and skills, i.e. incompetent.

I have no empirical research or data to show this. I can only hypothesise based on my observation of my play of QuizUp that I really enjoy and am good at to some extent. Also, this phenomenon of slipping back into conscious competence may be limited only to me and not the rest of the world (though I doubt it) and so this whole concept may be relevant only to me.

However, my concerns are two fold. First, in teaching new skills to the old dogs we may be negatively impacting on their overall competence at least temporarily (while their new skill competence gradually improves – learning curve) and while this may be happening we may not be able to recognise it. Secondly, once these doctors are in difficulty, we may be testing the skills of race car driving with a normal driving test template and failing them in both.

Whether this is purely theoretical or not, it is worth putting some research into this. It may be beneficial to both patients and doctors.


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Wednesday, 16 July 2014


Last year (2013) as my thank you for the BAPIO Award for “Outstanding contribution to the health services in the NHS and abroad” I had put together the compendium of my reflective writings over the last 25 years in the NHS (download here It contains my writings on various aspects of health services (not my research publications) and range from a one pager to very substantial documents like the Milroy Lecture. Now it was not until much later, years after I started writing, that I realised that what I was doing was reflection – the term reflective practice was not much in use then and indeed even now. I sort of fell into it, mainly as a way of improving my writing skills which were (are) essential for public health practice, and once I got the ‘bug’ I kept going and tackled increasingly complex subjects including my observations on medical leadership and about my time as the GMC Council member. I had discovered that writing made me think and make sense of what I had observed or done and most importantly how I could improve. 

The publication of the compendium has provided further impetus and I now want to find out more about reflective practice. I realised that I had approached the subject back to front. Until very recently I had very limited knowledge of the theory of reflective practice and I basically did what I felt like! I did not know ‘Reflection on Action’ from ‘Reflection in Action’. 

The definition that I find useful now is from Boud et al who define reflection as ‘‘a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to a new understanding and appreciation’’ (p. 19). Schon introduced the concept of the ‘‘reflective practitioner’’ as one who uses reflection as a tool for revisiting experience both to learn from it and for the framing of murky, complex problems of professional practice. (from 1) 

Simply put, critical reflection is the process of analysing, questioning, and reframing an experience in order to make an assessment of it for the purposes of learning (reflective learning) and/or to improve practice (reflective practice). (2)

Now, you must wonder why I am being so self-indulgent, and what does it mean for clinicians.

In this regard, this analysis probably sums it up

“If we take the example of a medical mistake, a superficial, educationally ineffective reflection will consist of a description of the events or a description accompanied by reasons such as the team/clinic was busy and other people failed in their responsibilities. A more useful and deeper reflection would include consideration of how and why decisions were made, underlying beliefs and values of both individuals and institutions, assumptions about roles, abilities and responsibilities, personal behavioural triggers, and similar past experiences (‘‘when pressed for time, I . . . ’’), contributing hospital/clinic circumstances and policies, other perspectives on the events (frank discussion with team members, consultation of the literature or other people who might provide alternative insights and interpretations), explicit notation of lessons learned and creation of a specific, timely, and measurable plan for personal and/or system change to avoid future similar errors. Effective reflection, then, requires time, effort and a willingness to question actions, underlying beliefs and values and to solicit different viewpoints. This ‘‘triple loop’’ approach moves beyond merely seeking an alternate plan for future similar experiences (single loop) or identifying reasons for the outcome (double loop) to also questioning
underlying conceptual frameworks and systems of power.” (2)

In essence, reflection is the basis of patient safety and is about learning from mistakes and putting things right. It is a bit like the “5 Whys’ approach to investigating incidents whereby one keeps asking why at each stage of questioning until you understand the root cause. 

Now, look at your, and others, practice- how far up this triple loop scale are you? When you make notes after CPD are you being critical/reflective enough? Is revalidation in danger of becoming a tick box exercise? Are we really doing enough for patient safety – do we know the root causes in our settings and are we addressing them, and why not? Are we ‘learners’ and able to constantly innovate and improve?

These are some fundamental questions facing us as doctors. We have to provide the leadership in these challenging times in the NHS, and central to being a leader is insight, self-awareness and ability to reflect and learn. In any case, the future of medicine is self- and life-long learning, and without a good grounding in reflection it will be difficult to cope with increasingly demanding jobs. 

So what could/should we do – can we do something together? Do you think we need more reflective practice in the NHS? Can you help me in my journey? Can I help you? Shall we form a group – virtual or real – to develop this further?
I will be very interested to hear from you- contact me at

16 JULY 2014

  1) Mann K, Jill AE, Macleod A. Reflection and reflective practice in health professions education: a systematic review. Adv in Health Sci Educ (2009) 14:595–621
 2) Aronson, L. Twelve tips for teaching reflection at all levels of medical education. Medical Teacher 2011; 33: 200–205

Saturday, 28 June 2014

Francis report - A very brief summary

The long awaited Francis report published in February 2013 makes for compelling reading. It comes at a time when many of us, healthcare professionals, have to deal with  ever increasing pressures to cut costs while at the same time striving to  maintain quality in the care we provide our patients. It is important for all of us to examine this report carefully and assimilate the key messages from it.


Robert Francis QC was first commissioned in July 2009 to chair a non-statutory inquiry in the then Mid Staffordshire General Hospital NHS Trust. This was  triggered by the high mortality rates of the trust  in 2007.The results of the first enquiry published in February 2010  concluded that there was a lack of basic care to patients across several wards and departments. The Board was accused of being more interested in achieving FT (Foundation Trust) status and concentrated more on statistics and reports than the outcomes of patient experience. More importantly it was damning on the role played by external organisations such as the PCT (Primary Care Trust) who had not identified the concerns till the investigation by HCC (Health Care Commission) in 2009. The enquiry recommended that Monitor  deauthorise the Mid Staffordshire NHS Foundation Trust when the power came into effect and suggested that there should be a public enquiry to investigate the issues highlighted in the first enquiry. The Department of Health and the Trust Board accepted all the recommendations of the first enquiry and the second enquiry, now a Public Enquiry was commissioned by the Government under the leadership of Robert Francis QC in June 2010.This report was finally published in February 2013 this year and consisted of over 1000 pages of detailed analysis and recommendations. The  shorter 125 pages of executive summary provide a good feel of the complete report.


The report  commences with a  consideration of key warning signs  of poor care that  existed  in Mid Staffs that should have triggered corrective action but did not.  The next section  explores issues relating to governance and culture of the Trust. This is followed by an examination of the role of  patient and public involvement groups, the commissioners, the SHA(Strategic Health Authority), and the regulators to understand what went wrong and to consider the role of other organisations. The conclusion of the report deals, with themes relevant  for the present and future with recommendations.


Robert QC unearths a whole series of events which in itself should have triggered an enquiry as early as 2004 with the loss of star rating when the Commission for Health Improvement (CHI) re-rated the Trust, and it went from a three star trust to zero stars. The HCC commissioned annual surveys of staff and patient opinion revealed that the trust was  in the worst performing 20% in the country. A whistle blowing incident involving a staff nurse’s report in 2007 was also ignored. Against a background of problems the trust announced staff cuts which was not questioned by the SHA. The HCC  meanwhile was preparing to investigate claims of poor care but did not know that at a national level the trust was being  considered  for FT status .Finally, Monitor did not know about HCC’s impending investigation until after it had given the FT status to the hospital in 2009. A breathtaking series of incidents over a period of 5 years  should have alerted someone, somewhere to the magnitude of the problem  unfolding within the hospital walls, but unfortunately did not.


The Inquiry report examines the role played by each organisation on what they should have known and done in response to concerns raised. It was critical of the trust board not  responding to the concerns that were raised to it, the SHA for raising these concerns to the Department of Health (DoH) at the time of the FT application and Monitor for awarding the FT status without  properly assessing the trust’s capability of delivering effective patient care. The lack of communication between various organisations was highlighted as the key problem. Further the report highlights the disconnect between  policy decisions being made and their practical implementation. It has been rightly pointed out that the setting of national standards in itself will not  “catch” a Mid Staffordshire but it is more importantly  the establishment of  robust and  effective methods to  police those standards, which will eventually prevent another mid Staffs occurring.


The report makes  290 recommendations and the following are some key ones.

A common culture made real throughout the system-Openness, transparency and candour

The report highlights the need for changing the current  culture of fear to a culture “where the only fear is the failure to uphold the fundamental standards and the caring culture.” The recommendation is that it should be  a criminal offence for any registered doctor or nurse or allied health professional or director of a registered or authorised organisation to obstruct the performance of these duties or dishonestly or recklessly make an untruthful statement to a regulator. 

Monitoring of compliance with fundamental standards

The importance of having clear and simple standards that both providers and patients can understand has been highlighted. These standards should be  informed by an evidence base and  be effectively measurable. The fundamental standards should be policed by a single regulator, the CQC, monitoring both compliance and the governance and financial sustainability. There is a recommendation that  NICE should produce evidence-based tools for establishing the staffing needs of each service.

Enforcement of compliance with fundamental standards

There is an expectation of zero tolerance; with a  service incapable of meeting fundamental standards not being permitted to continue. Further, non-compliance with a fundamental standard leading to death or serious harm of a patient should result in prosecution of as a criminal offence, unless the provider or individual concerned can show that it was not reasonably practical to avoid this.

Effective complaints handling

A new recommendation has been introduced  for an independent investigation of a complaint  to be  initiated by the provider trust under certain circumstances such as   if a complaint amounts to an allegation of a serious untoward incident or a complaint raises substantive issues of professional misconduct or the performance of senior managers.

Applying for foundation trust status

There is an ongoing recommendation for the merger of CQC and Monitor and  numerous suggestions for tightening up the process including physical inspection of site by CQC prior to awarding FT status.

Accountability of board level directors

The report tackles the issue of lack of accountability currently among board level directors.  A finding that a person is not  fit and proper to undertake the role of  Director may henceforth disqualify them  from being a director of any other healthcare organisation and they could themselves  be also reported  to the regulator.

Medical training and education

The report recommends that students and trainees should not be placed in organisations which do not comply with the fundamental standards. Further   those charged with overseeing and regulating these activities should now also make the protection of patients their priority. The General Medical Council’s system of reviewing the acceptability of the provision of training by healthcare providers must include a review of the sufficiency of the numbers and skills of available staff for the provision of training and to ensure patient safety in the course of training. 

Caring, compassionate and considerate nursing

The report has asked for an increased focus on a culture of compassion and caring in nurse recruitment, training and education. The report would like to see ward nurse managers work in a supervisory capacity and  not be office bound. The Nursing and Midwifery Council should introduce a system of revalidation similar to that of the GMC with a Responsible Officer for nursing in each trust. To tackle the issues of poor care noted among elderly patients, one suggestion is to create a new status of a registered older person’s nurse.

Quality accounts with information about an organisation’s compliance or non-compliance with the fundamental standards  should be made available on each trust’s website.

Robert QC has recommended that every organisation should announce at the earliest , its plans on how it was going to accept and implement the recommendations and within the year, publish a report with its progress towards these recommendations.

It is important that we participate in these changes in our organisation and make the improvements happen.


The Bristol enquiry was a wakeup call to the medical profession and it was believed, at the time, that lessons would be learnt. However this  do not appear to be the case and the Francis  report proves this.   The word “hindsight” occurred at least 123 times in the transcript of the oral hearing  and “benefit of hindsight” 378 times.  Empowered with the “hindsight” provided by the lessons from the Bristol enquiry and many others that followed, the Mid Staffs disaster should not have happened. Yet we let it happen.

The Francis report is yet another wake up call to professionals like us. As Robert Francis QC pointed out- the system cannot make the change for the better, it is the individuals in the system that can. Is there are a hospital near you or perhaps even yours who may be declared as the next “Mid Staffs”? We need to be courageous to speak up and stand up for the patients that we serve. The big question is ...will we?

 Robert Francis asks for a culture change in a climate fraught with tensions between management and clinicians. Consultant morale is the lowest it has been in years and not enough nurses can even be recruited into the posts. Further nursing profession regulation, could potentially make the nursing profession unattractive for new entrants. Talk of criminalising failure to deliver care may only drive the offenders deeper into the woodwork. People will be less likely to open up to their faults if they are afraid of being prosecuted. The report talk about routing out the blaming culture but till that is really done not much can be done about being open about mistakes.  As the management would like to put it, it is no longer a “no blame” culture but a “fair blame” culture-fair by whose standards, one wonders.

We have a government that has set targets for financial savings for healthcare organisations. The management unprepared for these challenges will make changes such as cutting manpower because that is the easiest way to save. Unless the government has a rethink of its financial strategy for the NHS, no real change can be made in the thinking or actions of the management. On the other hand, one could argue that a well qualified management team could identify cost cutting measures which do not sacrifice quality. The report’s recommendation to provide accreditation for management post holders and holding them more accountable for their performance may encourage individuals with the correct credentials to apply for these posts. Too often, managers in such posts are not specifically trained for them and tend learn more on the job rather than come prepared to deliver an effective role.

The Deaneries have been given a chance to influence the environment in which training takes place and must grab this opportunity to make an impact. It can only be a good thing for trainee doctors to be made aware of their responsibility to report deficiencies in care as a cultural change started amongst trainees is more likely to produce a next generation of doctors with a conscience-a conscience that will ensure that they act on behalf of their patients. 

Far too many organisations exist and each adds further bureaucratic   barriers to the transfer of information. The Francis report is welcomed as step in the right direction in highlighting this issue. Particularly welcome was the suggestion to not embark on another re-organisation but one wonders as to whether this will be followed.

While all this make for gloomy reading, one does need to make the change that Robert Francis has asked for in his report-patients are being treated poorly and as doctors we  have let it happen – we need  to overcome our squabbles and professional divides and  fight this together.

The Francis Report is a compelling read and I would advise every one of you to read it, if you have not done so already.


Consultant Anaesthetist

Director of Medical Education

Hull and East Yorkshire Hospitals NHS Trust



1) This article was originally written for and published by a BAPIO publication
2) This article was first blogged on the Success At Medical Interactions blog site which is part of Success At Medical Interactions interview skills course providers for doctors
3) Dr M Purva can be reached via twitter