The young dentist: How do you know what you don't know?

By Laura Wade

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Introduction

Nine years ago, a question was asked of me in a university dental school interview, and it has stuck with me. That question was: ‘How do you know what you don't know?' Riddled with anxiety and apprehension, I fumbled together an answer filled with textbooks, asking questions and trying to learn everything about everything. Needless to say, I didn't study at that university!

The question has stuck with me ever since. What on earth did they want me to say to that? Throughout my university years, I always thought to myself ‘What a stupid question, obviously you don't know what you don't know, or else you would know it, right?' However, as I progressed through dental school and beyond, phrases kept jumping out at me: ‘scope of practice', ‘insight', ‘conscious incompetence', ‘working within your knowledge and skills'; and I began to realise, the interviewers were not trying to catch me out, but to teach me a valuable lesson about dentistry, life, and myself.

The General Dental Council Standards state that one must maintain, develop and work within their professional knowledge and skills,¹ hence we must be confident and have enough insight into our own capabilities to know the limits of our professional knowledge and skills.

The four stages of competence

In February 1969, M Broadwell introduced a learning theory of ‘The four levels of teaching', later adapted to ‘The four stages of competence', as shown in Figure 1.² His initial theory related to the abilities of teachers to educate their students, however over the years this has been adapted to fit all kinds of teaching and learning, within a number of different professions and leadership roles.

Fig. 1 A diagram demonstrating the progression through the ‘four stages of competence', as described by Broadwell.²

He describes a ladder of competence, beginning with the ‘Unconscious Incompetent'. This is somebody who is incompetent within their field, but doesn't know it.² This was me, when I was in my dental school interview - I had no idea what I didn't know, and no idea how to find out. This stage can be dangerous, as there is a level of blissful unawareness of the potential impacts that can be had upon the receiver, whether this be a student, or in our case, a patient. The ignorance to the knowledge and skills can be applied to dentistry, whether it is regarding a topic at university that hasn't been covered yet, or a lack of understanding of the implications a certain treatment may have on a patient. You don't even know that what you don't know exists.

Next on the ladder, is the ‘Conscious Incompetent'. This person lacks knowledge and/or skills, but has an awareness of this. This is when we are willing to admit that we don't know, or we aren't capable of a certain thing.² We have discovered that we have more to learn, and we know how to do this. We ask for help, and seek to learn from our leaders, whether they be tutors at university, or colleagues whom we are inspired by. This stage can be demoralising and frustrating but is generally safe. Much like the prosthodontic clinics at university for me: The denture won't fit, I know why it won't fit, but I know I don't know how to make it fit! This is the answer to those interviewers' question: In this stage, you don't know what you don't know. At this stage, it is useful to know somebody who does know what you don't, that way you can learn from your mentor and progress to the next level of competence.

‘Conscious Competence' follows, and this is where one has mastered the skill, and knows they have. You know what works, how to make it work, and why it works, and you know that you know this. This person is focused, experimented and measured; they constantly review their work and look for more ideas and inspiration to improve the quality of their work. In dentistry, this might be when you're gaining confidence with taking teeth out, you know how to use a luxator and an elevator (and finally know the difference!), and you know which techniques work and don't work for you. At this stage we still have to concentrate on the skill, we know our capabilities, but we also know our limitations, we can extract that grade 1 mobile upper first molar, but present us with a disto-angular impacted lower wisdom tooth and we slide back down to the conscious incompetence stage.

Finally, Broadwell described the theory of ‘Unconscious Competence'. This is somebody who is good but doesn't know why. He describes that either the person doesn't have the knowledge of why something works or doesn't have to think about what they are doing, it comes naturally.² In dentistry this can be applied to the clinician who is so capable and experienced within their field, that their work comes as second nature, an effortless use of the skills they have developed over the years. How easy does a basic periodontal examination feel now? Something which is so simple, but to the unconscious incompetent, quite daunting and somewhat dangerous!

Application to dentistry

Throughout my dental career, I have really pondered over this question, and have noticed things along the way that have made me stop and think, ‘wow, this is what they were really talking about'.

I started my career in general dental practice as a Foundation Dentist, as do most new graduates. Starting as a dentist on your first day is absolutely petrifying, and you feel that all the knowledge and skills you have learned over the last five years disappear the second that first patient walks through the door.

Just six weeks before, you were ‘at the top of your game', a final year dental student who has passed all their exams, and can now officially call themselves ‘Dr', and your name is three letters longer! After passing finals, you feel that there is nothing about dentistry you don't know, and you are consciously competent, you know that you know everything you needed to know, or else you wouldn't have passed.

However, a new environment, new colleagues, new patients with new real-life, non-textbook problems; and back down the ladder you slip. You feel way out of your depth, no multiple choice papers could prepare you for this! I know all there is to know about the histology slide of mucous membrane pemphigoid, but what about Mrs X who has toothache that she can't specify where from? What about the denture that you just can't work out why it isn't fitting? How do you discuss money with a non-exempt patient? It's very easy to feel out of your depth, and then it hits you: there is so much you don't know.

You settle into your new role, and pick up patterns, develop a speel of post-operative instructions that you say faster than the terms and conditions in a radio advertisement, you become more comfortable, and this sort of stuff becomes second nature. You are so well supported by your trainer, and you know that they know what you don't, you learn what you are comfortable with and what you need support with, and eventually the latter becomes the former, and you become consciously competent within your role.

I progressed to my Dental Core Training roles, within Oral and Maxillofacial Surgery, and what a learning curve this was. Now, not only did I have to remember all my dental knowledge, but also apply new medical information and learn how to look after very poorly ward patients. I realised, I didn't know any of this! This can all be really scary, and it is easy to become anxious within this new role, because now people's lives can be on the line, and often you are the first person to assess the patient. However, this is where it really hit me about how important it is to know my capabilities, and know when, and how, to ask for help - yes, I can deal with the abscess that needs local incision and drainage in A&E, but the patient with acute submandibular swelling and airway compromise? I need help from someone more competent and confident than I.

Throughout my DCT years and now into my middle grade role, I have been delighted to observe junior colleagues progress through the stages of competence. Initially in OMFS, juniors are anxious to suture a small lip laceration, but three or four months into the job they are presenting cases of twenty-plus centimetre lacerations that they have closed themselves in the emergency department. It's all about knowing what you do and don't know. What I have found interesting over the early years of my career is that the more I learn, the more I realise I don't know.

I have discussed this with many of my senior colleagues, and one statement that really struck me during my DCT years was this: ‘In life you need to know three things: What you know, what you don't know, and somebody who knows what you don't'.

Conclusion

To those interviewers back in 2014, I would like to change my answer to the below.

The skill of knowing what we don't know allows us to shape our development as an individual and professional. Reflecting upon our knowledge and skills allows us to gain confidence and competence in that which we do know and acknowledging that which we don't. We cannot simply be the master of everything, but to practice safely and confidently, we must be able to identify areas where further development is required and evaluate situations with unpredictable outcomes to assess whether there is more information to be obtained.

Learning from experience demonstrates to us, albeit often in hindsight, that we once didn't know what we know now. Recognising these patterns can encourage us to seek guidance and develop an ability to understand our own limitations and learning needs. Within dentistry this owes to the importance of a personal development plan and continuing professional development; within life this owes to reflection, care and compassion to provide our patients with the best and safest care within our capabilities.