Unconscious Competence in Medical Training

There is a phrase in the medical world that a lot of doctors can relate to – Unconscious Competence. Sigmund Freud, the famous Austrian neurologist and psychiatrist, first described the unconscious as part of the mind that lay outside of someone’s conscience, working behind the scenes. Freud eventually started using the terms Ego, Superego, and Id, in replacement of the unconscious.

Despite the complexity of the unconscious mind in the field of psychiatry, in Medical and Surgical fields “unconscious competence” is used to describe the requirement that a physician have such a grasp of knowledge of how to take care of patients that he can do it in his sleep. The idea is to prepare the physician so that he can answer a hospital call half asleep or after he has been up all night and make the correct treatment decisions.

The theory of medical training is that if doctors can learn how to operate and care for patients when they are tired or sleepless, then they will be able to do this as practicing physicians. Thus training has always focused on volume and hours of work to expose medical trainees to the most rigorous work environment.

This was all fine and dandy until someone a few years ago looked under the covers and realized that doctors, despite their great handwriting and competence, were making a lot of medical errors out of sheer fatigue. Thus there was a backlash against the medical system reducing hours of training to 80 hours per week for all medical trainees. This rule was implemented only a few years ago.

Have things gotten better or worse? Are we training doctors that will not be unconsciously competent in the middle of the night?

It is too early to tell, but one thing is clear. Doctors and medical trainees are more well rested now so that when they do get called, they can actually wake up and do the work with vigor and passion. They are not working like ghosts in the night. They actually have a chance to be consciously competent.