Tools
Deliberate Practice in Medical Simulation
Introduction
You have likely heard the phrase practice makes perfect. Iterative phrases, such as practice makes permanent, and perfect practice makes perfect, may also be familiar. The nature versus nurture debate is also germane to this discussion relative to natural talent/ability versus what can be learned/acquired. In medical education, traditional methods of heavy didactics followed by short clerkships and electives emphasize knowledge acquisition over skills, as evidenced by the adage see one, do one, teach one. This approach implies virtually instantaneous mastery of new procedures and clinical skills with minimal if any, practice or instruction.
Methods of skill acquisition, professional development, and expert performance have long been studied and debated. K. Anders Ericcson introduced a descriptor for his perspective of how expertise, expert performance, and experts develop: deliberate practice (DP) is “when individuals engage in practice activities (which are, at least initially, designed by teachers and coaches) with full concentration on improving some specific aspect of performance.”[1] In addition to observable behaviors and technical skills, expert performers can verbalize their cognitive processes and mental imagery of the events.[2]
Ericcson and Smith empirically studied reproducible superior performance to investigate the underlying methods and mechanisms.[2] Ericsson and colleagues described five foundational elements necessary for instructors and learners to accomplish deliberate practice: (1) motivate the learners; (2) provide clearly defined learning objectives for specific tasks; (3) define precise, measurable metrics of performance; (4) engage in focused, repetitive practice of skills; and (5) deliver real-time, constructive, actionable feedback.[2][3]
This method, employed in an iterative, active cycle to provide ample opportunities for gradual refinements of learner performance, has been shown to yield significant improvements in performance.[2][3] Deliberate practice has been studied in typists, professional violinists, master chess players, and various athletic sports, including baseball, darts, tennis, and gymnastics.[2] Ericsson et al. studied the deliberate practice in expert musicians, which led to the theory that 10,000 hours of practice are needed to achieve expert performance.[3] In recent years, deliberate practice has been applied to the practice of medicine and medical education, fields of nursing, and many allied health professions from pre-clinical studies through post-graduate training and even into continuing education for practitioners.
Function
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Function
In clinical training/practice, it is rare that opportunities for repetitive clinician-patient skills present in situ. Thus, simulation is an excellent method and learning environment to practice skills in repetition, then escalating difficulty, with an instructor/coach providing feedback, including time for reflections, and having low-stakes concerning medical errors and patient harm.[4] The technical and cognitive skills that are the learning objectives and assigned tasks are often not part of normal clinical practice but are fundamental micro-skills that improve some particular aspects of performance by modifying the control of behavior and thoughts relevant to situational factors and the environment.[5][4] Through empirical research, simulation-based medical education (SBEM) has demonstrated to (a) increase knowledge, (b) provide opportunities for practice, and (c) allow for formative and summative assessment.[3][5][4][6]
Curriculum Development
One useful framework is the SMART goals to create specific, measurable, achievable, realistic, and timely learning objectives. Development of assessments, learning activities, performance metrics, and learning outcomes may be guided by modification of SMART goals as the model does not fully apply to these elements. Setting learner expectations is key for both behavioral and cognitive outcomes. Alignment of assessments, which are ideally developed after learning objectives and before learning activities, supports congruency among these three instructional design elements. Formative assessment is embedded in the repeated practice with coaching/instruction and immediate feedback to the learner, preferably verbal in real-time.[7] Summative assessments should be developed to include behaviors/skills and knowledge, whether by written, computer-based testing, verbal, or direct and indirect observational methods.[8]
Learner motivation is an essential requirement for a well-designed, effective DP. Self-efficacy models list internal and external drivers, but of course, teachers can most readily affect learner motivation via external means. Summative assessments are rated highest, with explicitly established relevance as second (i.e., future summative assessment, required professional activity/skill, a prerequisite to other required skills). Applied skills, that is, skills which the learners anticipate to be valuable or necessary for clinical performance and patient care, rank higher than prerequisite skills. Level of importance may be influenced by teacher/coach selection with respect to their area of expertise (medical specialty/discipline), degree of expertise (years in practice), and near-peer level relationships as having a greater influence on learners than distant, often senior-level faculty. Also, some attention is necessary to delineate the skill hierarchy or degree of relevance; engaging learners in a discussion of their perception may inform the teacher as to the individual student zone of proximal development.[9]
Procedural Skills Assessment
Embedded within the premise of Ericsson's model of procedural skill acquisition is skill assessment. The model requires a coach to observe the practitioner's performance and provide immediate, actional, feedback to incorporate the feedback into the subsequent performance event. Thus, assessment during DP is formative as the goal is to improve performance. When performing a skill for a summative assessment with the intent to pass judgment on practitioner competency, unsatisfactory performance may prompt a course of remediation to include DP as a means by which the practitioner may practice the skill and improve until achieving competency. Documentation of performance is common via a checklist or rubric.
Continuing Education
Once a professional achieves an acceptable skill level, more experience does not, by itself, lead to improvements. “Deliberate efforts to improve one’s performance beyond its current level demands full concentration and often requires problem-solving and better methods of performing the tasks.”[2] This has lead to increased use of specialty-specific interventions, such as surgical skills coaching and hands-on training sessions for airway management and point of care ultrasound.[10][11][12]
Clinical Significance
The end goal of SBEM deliberate practice of technical and cognitive skills is for the transfer of those skills from simulation-based practice to clinical practice situations. Studies have shown deliberate practice to be effective in the performance of many clinical skills in the technical/procedural category: central venous catheter placement;[13][14][15] lumbar puncture;[16] spinal anesthesia;[17] tissue-based coronary surgery;[18] hemodialysis catheter insertion by nephrology fellows;[19] thoracentesis by internal medicine residents;[20] operative performance by surgical residents in obstetrics and gynecology,[21] otolaryngology,[22] and surgery[23][24][25][26][27]; anesthesiology training;[28][29] cricothyrotomy.[30]
Additional studies have supported DP use for teaching and learning skills which require a higher cognitive load (i.e., less likely to be automated as rote muscle memory) and some aspect of hands-on, such as point of care ultrasound (POCUS);[12][31] ultrasound guided regional anesthesia;[32] and team function dynamics during simulated pediatric resuscitation.[33]
Thus, SBEM deliberate practice can be used to acquire new skills, refresh on previously learned but seldom used skills, and continually improve via self-reflection and peer feedback.[34] The range of subject matter and audiences are vast and range from highly technical skills, such as neurosurgery, to soft skills in communication and self-assessment. Limits to utilizing simulation and deliberate practice in medical education are seemingly only within the mind of the course developer.
Enhancing Healthcare Team Outcomes
So-called soft skills, including leadership, communication, and interpersonal skills, have been taught and learned via DP: standardized handoff communication for first-year residents;[35][36] cardiology course for internal medicine residents;[37] oral case presentation skills for medical students;[38] radiograph interpretation of pediatric residents;[39] debriefing with good judgment;[40][41] code team leadership skills for senior residents;[42] patient assessments by medical students;[43] and interns ordering blood products.[44]
By extrapolating the target audience from primary medical learners, several studies have included secondary audiences vital to medical education. For instance, a few studies utilized simulation and DP for training standardized patients and instructional facilitators.[45]
References
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Level 3 (low-level) evidenceEricsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic medicine : journal of the Association of American Medical Colleges. 2004 Oct:79(10 Suppl):S70-81 [PubMed PMID: 15383395]
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Barsuk JH, McGaghie WC, Cohen ER, Balachandran JS, Wayne DB. Use of simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit. Journal of hospital medicine. 2009 Sep:4(7):397-403. doi: 10.1002/jhm.468. Epub [PubMed PMID: 19753568]
Level 2 (mid-level) evidenceCorvetto MA, Pedemonte JC, Varas D, Fuentes C, Altermatt FR. Simulation-based training program with deliberate practice for ultrasound-guided jugular central venous catheter placement. Acta anaesthesiologica Scandinavica. 2017 Oct:61(9):1184-1191. doi: 10.1111/aas.12937. Epub 2017 Jul 6 [PubMed PMID: 28685812]
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Nesbitt JC, St Julien J, Absi TS, Ahmad RM, Grogan EL, Balaguer JM, Lambright ES, Deppen SA, Wu H, Putnam JB. Tissue-based coronary surgery simulation: medical student deliberate practice can achieve equivalency to senior surgery residents. The Journal of thoracic and cardiovascular surgery. 2013 Jun:145(6):1453-8; discussion 1458-9. doi: 10.1016/j.jtcvs.2013.02.048. Epub 2013 Mar 15 [PubMed PMID: 23499474]
Level 3 (low-level) evidenceBarsuk JH, Ahya SN, Cohen ER, McGaghie WC, Wayne DB. Mastery learning of temporary hemodialysis catheter insertion by nephrology fellows using simulation technology and deliberate practice. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2009 Jul:54(1):70-6. doi: 10.1053/j.ajkd.2008.12.041. Epub 2009 Apr 19 [PubMed PMID: 19376620]
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Level 1 (high-level) evidencePusic M, Pecaric M, Boutis K. How much practice is enough? Using learning curves to assess the deliberate practice of radiograph interpretation. Academic medicine : journal of the Association of American Medical Colleges. 2011 Jun:86(6):731-6. doi: 10.1097/ACM.0b013e3182178c3c. Epub [PubMed PMID: 21512374]
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Level 3 (low-level) evidenceJoyce KM, Byrne D, O'Connor P, Lydon SM, Kerin MJ. An evaluation of the use of deliberate practice and simulation to train interns in requesting blood products. Simulation in healthcare : journal of the Society for Simulation in Healthcare. 2015 Apr:10(2):92-7. doi: 10.1097/SIH.0000000000000070. Epub [PubMed PMID: 25710316]
Bond WF, Gonzalez HC, Funk AM, Fehr LS, McGarvey JS, Svendsen JD, Sawicki R. Deliberate Practice with Standardized Patient Actors and the Development of Formative Feedback for Advance Care Planning Facilitators. Journal of palliative medicine. 2017 Jun:20(6):631-637. doi: 10.1089/jpm.2016.0431. Epub 2017 Jan 13 [PubMed PMID: 28085541]