Experts and their unknown knowns

On the 12th February 2002, Donald Rumsfeld uttered his most memorable words as US Secretary of Defence:

"Reports that say that something hasn't happened are always interesting to me, because, as we know, there are known knowns; there are things we know that we know. There are known unknowns. That is to say, there are things that we now know we don't know. But there are also unknown unknowns. There are things we do not know we don't know" (1)

Wikipedia has a nice article on this statement, including the missing pair: unknown knowns. Rumsfeld does not mention it, perhaps because there is some confusion about what an "unknown known" is. The Wikipedia article calls it "the most dangerous type of unknown" but then (at the time of writing and with an understanding that Wikipedia is constantly edited) goes on to make a bit of a hash trying to explain it. There is a suggestion that an "unknown known" is the claim that weapons of mass destruction existed in Iraq, or the Abu Ghraib scandal or things we refuse to acknowledge that we know.

Personally I prefer to think of "unknown knowns" as things we didn't know we knew. This is what Dörner, in his book Logic of Failure, is talking about when he says he knew a doctor who could diagnose a disease with great certainty but this doctor didn't know how he did it. Dörner explains it as a type of intuition and goes on to comment that experts often display this type of intuition. This integrates very nicely with a 4-stage framework (first developed by Noel Burch) for looking at expertise:

1. Unconsciously incompetent: unknown unknown (The total beginner who has no idea what he doesn't know and is oblivious to the breadth and depth of possible knowledge. This is a dangerous place to be and a scary person to be looking after you in an emergency) 
2. Consciously incompetent: known unknown (The novice who has become aware of how little he/she knows. A somewhat less dangerous place to be and now, instead of having a scary person looking after you, you have a scared person looking after you.)
3. Consciously competent: known known (The journeyman who knows a lot but has to spend a lot of time thinking about what he/she is going to do.)
4. Unconsciously competent: unknown known (The expert who has a sixth sense about things which are about to go wrong or can stop a situation from escalating without telling you how they knew what to do.)

In many ways then the extremes of the framework are the most untroubled places to be; at one end ignorance is bliss and at the other end ignorance is due to the achievement of expertise.

This 4-stage competence framework allows us to see how a learner may progress and implies that moving through the 4 stages is beneficial without drawbacks. However, later on in his book Dörner goes on to explain how more information (loss of the unknown) may be detrimental:

"Anyone who has a lot of information, thinks a lot, and by thinking increases his understanding of a situation will have not less but more trouble coming to a clear decision... We realize how much we still don't know, and we feel a strong desire to learn more. And so we gather more information only to become more acutely aware of how little we know..."(p. 99)

In terms of how the framework relates to simulation-based education, I would like to think that it can help us understand at which stage a participant is. This knowledge should allow the course faculty to tailor the course to the participant. I would also like to think that simulation lends itself well to the little-known 5th stage of competence:

5. Consciously aware of unconscious competence: known unknown known (An ability to reflect on and examine the behaviours and actions one is carrying out as an expert.)

The Elaine Bromiley case involved a number of experts in anaesthesia and ENT surgery who failed to do the right thing. Partly due to an underdeveloped final stage of competence, these experts were not able to reflect in situ  and realise what the correct sequence of actions should be. Simulation with debriefing allows experts to watch how they make mistakes and learn to develop mechanisms for preventing them. Unfortunately it is experts (consultants) who we see least often in the simulation suite as participants and this needs to change.