I recently had to recertify for one of my key medical competencies at work, with the one-day training course being run at the regional hospital I work at. Although the training was delivered by an outstanding instructor, and was highly engaging, it was run in a conference room with equipment that belonged to the training provider, and differed slightly to the kit we use in our facility. Furthermore, the group recertifying that day were not likely to be the ones working together when an emergency occurs. It got me thinking that a better way to have run the training would have been in the teams we actually work in, in our hospital’s actual resuscitation bay, with the equipment we use on a day-to-day basis.

The realisation that repetitive and realistic training is fundamental to optimal performance of a skill is not new. In the mid 600s B.C.E, the Greek lyrical poet Archilochos is credited with the quotation, “We don’t rise to the level of our expectations, we fall to the level of our training.” Furthermore, we often hear the old adage, “train as you’re going to fight,” but how many of us actually apply it to our role?

Training as we were going to fight was something that we did very well during tactical medical training in the military units I served with, so much so that by the time most of us found ourselves in a real-life tactical trauma situation, we found that the skills required came to us instinctively, and often without much conscious thought.

This didn’t happen by chance, and while I didn’t appreciate it when I first went through the training pipeline myself, there was a very deliberate process in place to program the requisite skills into us, to give us the best chance of success under the duress of a battlefield trauma medical situation. The training philosophy applied is known as reality-based training (RBT), and is best described in the definitive text on the subject, “Training at the Speed of Life,” written by Kenneth Murray (2006). To understand how RBT works, it is useful to have a brief look at some of the theory behind it.

When learning any new skill, there are four levels of integration during its acquisition (Grinder, cited in Murray 2006, p. 25):

  • Unconscious incompetence
  • Conscious incompetence
  • Conscious competence
  • Unconscious competence

Put simply, this translates as follows:

  • You don’t know what you don’t know
  • You know what you don’t know and can’t do it
  • You can do it, but you have to think hard about it
  • You can do it on autopilot

To illustrate the importance of programming the correct skills into an operator in any field, I would like to quote from an outstanding reference in “Deadly Force Encounters” (Artwohl 1997) regarding experiences of law enforcement officers during gunfights:

“…under sudden life-threatening stress, individuals will likely exhibit behavior based on past experiences that they will automatically produce without conscious thought. This means [that there is a necessity to] not only [train] officers in appropriate tactics, but also [to provide] sufficient repetition under stress so that new behaviors will automatically take precedent over any previously learned, potentially inappropriate behaviors that they possessed before becoming an officer.”

The specialist skill that I am most familiar with is that of tactical medicine. For that reason, I will use the training process of a special operations medic to illustrate the various phases of skill acquisition, and how they are achieved.

Ideally, it can be seen that unconscious competence is the level that needs to be reached in order for a medic to reliably function well in the high-stress combat-trauma environment. Reaching this level of skill acquisition allows the combat medic to perform his or her fundamental, life-saving medical skills, such as arterial tourniquet application, without committing higher-level conscious thought to the intervention. This allows the higher-order thought processes to be devoted to other considerations, such as maintaining situational awareness of the tactical situation, and beginning to mentally formulate a report of the casualty (nine-liner) for higher reporting.

Critical to achieving this level of unconscious competence is a structured escalation of training from the basic component skills of the combat medic trade through to the repeated application of those skills in high-fidelity RBT scenarios.

Taking the example of training a special operations combat medic to operate at the highest level under duress, I am going to start with them posting into an SO unit at a training level of unconscious incompetence. At that stage in their career, they will have passed their basic medic training, and generally served in one or two other units prior to posting into SO. They may have a basic understanding of the combat medic role in a special operations unit, however they are generally oblivious to the specifics and full implications of the role.

The first step toward reaching unconscious competence is opening the medic’s eyes to the full spectrum of what is expected of them in the role, and thus moving them to a state of conscious incompetence. This can be a humbling and somewhat demoralizing experience for the medic, when all of a sudden they realise that they are inadequate for the role at their current level of training. As instructors, it is important to manage this stage of an individual’s training well, in order to build rather than destroy confidence. For the right medic, however, the move to conscious incompetence is highly motivating to learn the requisite skills and become a proficient operator.

Once a medic knows what they don’t know, the next step is to start filling the knowledge gaps with appropriate training. This stage involves a progressive introduction to skills, which is best provided initially with theoretical lessons and individual practical skills practice. It is appropriate to use classroom-based lessons initially at this level of training, and it is important to ensure that the medic has a firm grasp on the basic individual skills before progressing to RBT scenarios. Progression too rapidly to RBT will overwhelm the medic and once again destroy rather than build confidence, however it is equally important to move quickly on to RBT once the basic skills have been mastered.

At this stage, the medic has reached a state of conscious competence, and will be able to perform their role well in a training context, however it will take their full concentration to do so. They will often be largely oblivious to the overarching tactical context of the scenario around them, and can easily be distracted from the task at hand by asking them a question. A good test that I used to use to assess whether a medic was at the level of conscious competence was to ask them for casualty information while they were involved in a scenario. At this point, the consciously competent medic would stop doing what they were doing and look up to give me the casualty information. When prompted to keep treating the casualty and tell me the information, they would go back to treating with competence but would stop talking.

The Pic of the Day: Hand-to-Hand Combat Training

Read Next: The Pic of the Day: Hand-to-Hand Combat Training

This was an excellent illustration that they couldn’t manage both tasks simultaneously due to their higher level thought being devoted to the function of casualty treatment, with no processing capacity left to generate and verbalize the casualty information. It was at the point when a medic could be performing their casualty management while reeling off casualty information to me that I was confident that they had reached unconscious competence, and were approaching readiness for their full role as an SO medic.

Once the medic had reached a state of unconscious competence on a daytime single-casualty scenario, the next step was was to start introducing additional factors, such as low-light conditions, multiple-casualty scenarios, and higher-fidelity training models such as live tissue. Every scenario was done with the exact same equipment as the medic would be carrying on the job, and always with the exact same uniform, body armor, helmet, rifle etc. that the medic would be using.


Tourniquets and other medical equipment would be positioned consistently on the medic’s kit throughout training as to program the muscle memory to reach instinctively to the right spot for any given piece of equipment, even in the dark. If the medic was being deployed to a cold climate, training was done in the cold, as to experience firsthand the challenges of medically managing a trauma casualty in cold environments.



If the medic was being deployed to a hot environment, once again, training was done for that environment, so there were no surprises when they reached their destination.

Once the skills were mastered during the day, training was done in low-light conditions such as smoke and night.

CUF smoke

Photo courtesy of Department of Defense.

(The following video highlights the complexities of providing care under fire on night vision, using high-fidelity simulation.)

Training was done in helicopters. The following series of screen shots are taken from a tactical evacuation training activity done as pre-deployment validation before one of my trips. Less than a month later, I found myself  in the back of a Black Hawk in Afghanistan with the exact same medic across from me, managing two IED blast victims similar to the ones in this training scenario. It went smoothly that day because we had trained as we were going to fight.

Tac Evac 1 Tac Evac 2 Tac Evac 3 Tac Evac 4 Tac Evac 5

Training was also conducted on the water.

And by the time the real scenario came around, the medic would have reached a state of unconscious competence, and be prepared to respond appropriately to a casualty situation in a complex tactical environment. (The gunshot wound casualty in the following video is the AK-47 wound case study previously published here on SOFREP.)

In this article I have chosen to use the example of training a special operations combat medic to illustrate Grinder’s levels of skill acquisition and the crucial importance of reality-based training, however the principles are equally applicable to any operator in any field. Training should be graduated at first, and then when the basic skills are solidified, RBT should be introduced in scenarios as close to the real environment as possible. I have been incredibly privileged to have been a part of military units that had access to budgets and equipment that allowed us to create high-fidelity training scenarios, however I feel that the same training outcomes can be achieved with a far smaller budget, and with less access to toys.

The key to creating a meaningful training environment is to engage the student with a scenario that is relevant to them, and if you can achieve that, the realism is of less importance. I have watched medics 100 percent engaged in trauma scenarios using very low-fidelity training models because they could see the relevance in the training. Likewise, I have watched students fail to engage in live-tissue training sessions, with real arterial bleeding from an animal model, because they failed to see the relevance of the training to them. If relevance and realism can be achieved in a training environment, then student engagement and positive training outcomes are almost guaranteed.

Finally, I’d like to address the idiom, “Those who can, do; those who can’t, teach.” Although this is sadly true in some instances, I feel it is only a half truth overall. Those who have done, and then choose to teach others, are the key to retaining corporate knowledge in an organization, and ensuring that hard-won lessons do not have to be relearned. In the instance of a special operations combat medic, relearning lessons can mean an unnecessary death of a teammate on the battlefield.

Those who have done, and then choose to teach, have the power to multiply their capability exponentially by imparting their skills on the next generation. I can think of many instructors over my years in the military who I owe an infinite debt of gratitude to for investing their time in me to ensure that in my moment of need, I had the skill set to rise to the challenge. To those instructors, and to all those out there who invest their time in a similar fashion, thank you for training others as they are going to fight.

Questions and comments are welcome. Cheers.

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Artwohl, A, Christensen, LW 1997, Deadly Force Encounters: What cops need to know mentally and physically to prepare for and survive a gunfight, Paladin Press, Boulder, CO.

Murray, K 2006, Training at the Speed of Life. The definitive textbook for military and law enforcement Reality Based Training, Armiger Publications, Gotha FL.