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How Miller’s Hidden Pyramid may shift Denial to Dissonance



Brennan describes three outcomes of Appraisal: 

  • Self-affirmation
  • Dissonance
  • Denial

It can be challenging for Appraisers to help Appraisees shift denial to dissonance. I have found Miller's Pyramid may help to visualize the stages of competency, but there are more core attributes to 'being a good doctor' - of care, compassion, and looking out for vulnerable colleagues.

To draw attention to vulnerability and denial, I illustrate these problems as the flip-side of competency with Miller's Hidden Pyramid:

   Miller's Hidden Pyramid JMM


To explore Appraisers' views about Brennan’s Outcomes of Appraisal, and their experience of using Miller’s Hidden Pyramid.


Wessex Appraisal Service approved the study to ask Appraisers in a Locality Group their opinions (n=24). The research is qualitative asking for free-text replies. The response rate was 50% (n=12), and analysed following Dealing With Qualitative Data (Wellington).


1. Have you experienced the outcomes of Appraisal of self-affirmation, dissonance, and denial? Did you feel equipped to recognise the outcome? How did you deal with it?

All the Appraisers had experienced these outcomes:

  • ‘I have come across these many times’.
  • ‘Yes, but haven’t looked to name them in such terms’.

All the Appraisers felt equipped to recognise these outcomes, dealing with it in their own experienced ways:

  • ‘I hope I have been able to facilitate the outcomes of dissonance and identify the positive elements of self-affirmation, and nudge people away from denial without being confrontational and elicit some insight’.
  • ‘Denial is hard to deal with, but I have found it useful to reflect back to an appraisee to trigger change’.

2. Have you used Miller’s Pyramid or other methods to nudge reflection? How does this affect outcomes?

Only one Appraiser had previous experience of Miller’s Pyramid:

  • ‘It is useful when doctors are learning a new skill’.

Others used:

  • ‘Reflection’... ‘Timeline of burnout’... ‘I use my own metaphors and models’.
  • ‘I use a what if? What would you change? How do you feel?’.
  • ‘Sometimes reflection works, but sometimes it appears too challenging’... 'many people are stuck in entrenched patterns of behaviour’.
  • ‘I find out the issues, then make a PDP item towards them’.

3. Do you feel equipped to help vulnerable Appraisees? Do you think Miller’s Hidden Pyramid may help make you more self-aware and understand Appraisee vulnerability?

All the Appraisers felt experienced to deal with vulnerable Appraisees:

  • ‘I do feel equipped to deal with vulnerable Appraisees, there is a huge amount of support out there’.
  • ‘Yes, I feel able to help most vulnerable Appraisees, if they want help’.
  • ‘I do, but there are limitations to what we can achieve’.

The Appraisers’ responses show an openness to learn and share ideas to develop as Appraisers, with many feeling Miller’s Hidden Pyramid would be useful:

  • ‘I have been an educator for a long time, particularly dealing with vulnerable trainees. I think Miller’s Hidden Pyramid would be useful’.
  • ‘Now that I am aware of Miller’s Pyramid, I think it may be useful in the future to moving a doctor to dissonance’.


1. Brennan’s Outcomes of Appraisal, Self-affirmation, Dissonance and Denial should be included in Appraiser training for understanding and improving outcomes.

2. Supporting vulnerable doctors at Appraisal is dependent on the Appraiser’s skills. These skills are enhanced by Appraiser training.

3. Miller’s Hidden Pyramid is an effective visual tool to show Vulnerability as the flip-side of Competency in Medical Education and Appraiser Training.


Dr Ferguson has been a GP for over 30 years and an Appraiser since 2003. He views Appraisal as an opportunity to reflect more widely, encourage new ideas, and ensure a healthy work-life balance.