Miller's famous pyramid of competence starts with knowledge at the bottom level, when the clinician “knows” the facts.1 Superior competence is achieved when the clinician can use knowledge in a particular context, “knows how.” Better still, “shows how” indicates that when tested, the clinician can show practical application of the knowledge. The peak level of “does” refers to actual performance in practice. But is there not a missing concept here—that of “knows about”?

I was struck by a rapid response to Mrs Patel's case from a doctor who had previously shown his competence around the thyroid issue in the first week. …