Knowing it isn't doing it

The idea in one sentence: knowing about something, knowing how to do it, showing you can do it, and actually doing it at work are four different things, and each needs a different kind of check.

You’ve seen this already

Think about baking bread. You can know that bread needs flour, water, yeast and time. You can know how: talk someone through kneading and proving. You can show how: bake a decent loaf at a class, with the teacher beside you. And you can do it: turn out a good loaf at home on a busy Sunday, with the children wanting lunch.

Each step up is harder, and each needs a different kind of proof. A quiz on ingredients tells you nothing about the Sunday loaf.

Why it matters for your teaching

Picture these four steps as a pyramid, with knows at the bottom and does at the top. A lot of the checking in healthcare training sits near the bottom. A multiple-choice test tells you what someone knows. It tells you very little about what they will do on a busy shift.

The pyramid also works as a planning tool. The verb in your outcome decides which level you’re aiming at, and so what you’d need to see:

Level	An outcome might say	How you’d know
Knows	”List the signs of sepsis”	A quick quiz
Knows how	”Explain what you’d do if…”	Talk me through it
Shows how	”Demonstrate the new hoist on a colleague”	Watch them do it in a practice setting
Does	”Uses the escalation tool on the ward”	Watch it in real work, or ask colleagues

“Be aware of” doesn’t make it onto the pyramid at all. You can’t watch someone being aware, so you can’t check it.

Where it happens matters too. “Explain the new inhaler to a patient on the ward” is does, even though the verb is “explain”. This is the heart of Teaching That Lands: start with what people need to do differently. Pick a verb you could watch, and you’ve already decided how you’ll know your teaching worked.

Try this

• Choose your level on purpose. Not every session needs to reach does. A short update might rightly aim at knows. But if the change you want is in practice, an outcome at knows won’t get you there.
• Let the verb pick the check. Write the outcome, then ask: what would I need to see? If the answer is “a quiz” and the verb is “demonstrate”, one of them needs to change.
• Give practice, not more content. You can’t get people to shows how by adding slides. They need to rehearse the real thing, with the real kit if possible.
• Look more than once for does. Real performance varies from day to day. Several short observations over time tell you more than one big sign-off.

How sure are we?

The pyramid is a way of thinking, not a tested finding or a measuring scale. It came from one experienced doctor’s argument, not from an experiment. It is very widely used in health professions education because it is simple and makes a real point: knowing is not the same as doing.

The levels blur in practice. Explaining can be knows how in a classroom and does at a bedside. Later writers added a level above does, called is, for when the role becomes part of who someone is (Cruess and colleagues, 2016). Checking the top of the pyramid well is hard: it takes repeated observation in real work, not one test (van der Vleuten and Schuwirth, 2005).

One common misreading is that higher is always better. The right level is the one that matches what people need to do.

Where it comes from

George Miller, an American doctor and a pioneer of medical education, drew the pyramid in a short paper in 1990. He wanted to show how most tests of doctors checked what they knew, not what they did with patients. It is now used well beyond medicine.