One would expect deliberate practice training to be better than no training. More interesting questions are whether deliberate practice has benefits compared to other educational endeavors and whether deliberate practice compares favorably with interventions that hold students’ attention in an equally engaging fashion. Two of the studies in Table 2 deserve attention on these issues. The Bruppacher et al.53 investigation compared deliberate practice training incorporated into simulation versus an interactive seminar, both 2 hours, for teaching residents how to wean patients from cardiopulmonary bypass. The seminar attempted to engage students by discussing real cases, using multimedia aids and conducting a back-and-forth discussion between the residents and faculty. The deliberate practice training proved superior to the seminar, and the difference persisted for at least 5 weeks, indicating a period of skill retention. Since the outcome was measured in weaning an actual patient from bypass, deliberate practice had an apparent impact on real-life practice, an outcome that matters.56
The other example, Johnson et al.,50 compared 2 methods of training residents how to manage adverse airway and respiratory events during anesthesia. Both groups received 40 didactic presentations on anesthetic management and simulation sessions covering 5 different scenarios. In the control group, the didactic sessions covered the knowledge and abilities a clinician would need, and the simulation sessions focused on steps that would be taken to manage airway and respiratory events. In contrast, the 15 of the 40 didactic sessions presented to the experimental group were organized around part task training, a method to break medical tasks into smaller sequential components following a checklist. The participants mentally rehearsed the sequences until they were ingrained, that is, successful deliberate practice. The simulation training for the experimental group also differed in requiring deliberate practice on crisis management. The outcome was that the experimental group demonstrated greater skill in handling unfamiliar adverse anesthetic events during a simulation test. The noteworthy point about this study was that it controlled to some extent for level of engagement by giving experimental and control groups the same simulation scenarios. Thus, the difference in outcome could be attributed in part to deliberate practice.
Deliberate Practice Is Feasible During Anesthesiology Training
The elements of deliberate practice can be incorporated into clinical teaching encounters in various forums.57 The focus can be on any anesthetic skill where opportunities to work on a problem occur repeatedly. For example, every case presents opportunities to communicate with the patient and the operative team and to assess the patient’s preoperative condition. Common anesthetic issues, such as treating hypotension, assessing anesthetic depth, evaluating volume responsiveness, or managing treatment, occur so frequently in anesthetized patients that residents may face a particular problem and practice it repeatedly during a single case. Other management issues, such as controlling the airway or planning emergence, can be practiced many times over the course of a few days. Deliberate practice for special issues, such as management of aortic stenosis or how to perform an ultrasound-guided regional anesthetic, is facilitated by subspecialty rotations, which focus residents on specific operations, procedures, and management issues within a brief time period.
Discussion formats allow teaching in a setting that does not compete with clinical care. They are appropriate for deliberate practice with nontechnical skills and cognitive skills. For example, a resident can practice communication skills, planning, and decision making by engaging in preoperative discussions with the faculty supervisor before each case. Mock oral examinations give residents practice in exercising knowledge and a range of cognitive skills, as well as preparation for the real examinations. Since adult learners tend to respond well in active learning situations,58,59 discussions should elicit audience participation, make students exercise decision-making skills, and push them to extend their expertise.
Some events, such as some anesthetic crises and rare operations, are so uncommon that residents may require training outside of the clinical arena to gain experience.60 Simulation provides opportunities to schedule training, control the environment, provide nearly unlimited chances to practice, and avoid risk to patients.61–64 Motor skills, such as airway management, spinal and epidural placement, nerve blocks, line insertion, and ultrasound techniques, can be practiced on partial task trainers,65–67 simple simulators that focus on teaching specific skills or concepts rather than management of the whole patient.
OPTIMIZING DELIBERATE PRACTICE
In recent years, cognitive psychology research has addressed the learning forms that increase the effectiveness of deliberate practice and identified several effective learning strategies. An article by Dunlosky68 provides a good nontechnical review.
One strategy is to consider testing not just for assessment, but also as a potent learning event stimulating retrieval from long-term memory.69 In one illustrative experiment,70 subjects underwent an acute test of recall after studying a list of words. They displayed greater accuracy on a delayed final test than did subjects who performed an equivalent amount of additional study in lieu of the acute testing. Testing contributes to learning across numerous domains and is effective in both laboratory and natural settings. The benefit is most profound when the learner receives feedback about the correct test answers,71 consistent with the importance of feedback in deliberate practice in general.
Testing-based learning can be incorporated into deliberate practice by alternating study and testing. For example, instead of reading a section of text a second time, learners could review the topic heading, test themselves by recalling as much of the section content as possible, and then read the section content to obtain feedback about their recall. In transesophageal echocardiography, an instructor could guide a resident in obtaining the standard views, test performance by asking the resident to demonstrate the complete examination, and then comment on the view quality.
A second robust learning strategy is distributed practice. For a fixed amount of learning time, splitting the time into multiple sessions over hours or days (distributing the practice) yields markedly better long-term retention of learning than does performing all the practice in a single long sitting. A body of evidence supports the effectiveness of distributed practice for a variety of tasks in both laboratory and authentic educational contexts.72,73 Distributed practice can arise naturally in anesthesiology education, since training events, such as management of hypotension, frequently recur from one patient to the next.
A third promising approach to optimize deliberate practice is task interleaving. For example, if 4 distinct types of problems (A, B, C, and D) require practice, long-term learning is enhanced by interleaving (mixing or shuffling) those problem types during practice (i.e., A, B, C, D, B, C, D, A, etc.) as opposed to blocking them (e.g., A, A, A, A, B, B, B, B, etc.). In a study involving 4 different computational tasks, interleaving practice yielded a 300% increase in accuracy on a delayed test compared to a blocking strategy.74 In the previous echocardiography example, the interleaving could involve practice on obtaining specific views interspersed with practice on assessing contractility and on valve function. The benefit of task interleaving might be augmented by distributing the echocardiography practice over several sessions as well.
Another potentially beneficial method is guided discovery learning, in which a learner is provided with limited explicit instruction and then must discover the solution to a problem alone. This method from constructivist theory is based on the premise that people learn effectively by building their own knowledge.75,76 Assisted, or enhanced, discovery learning typically yields better outcomes than does direct instruction when it includes a support framework (e.g., an outline of how to solve the problem), worked examples, timely feedback to direct the learner away from incorrect solution paths, and the ability for the learner to solicit explanations.77,78 These principles are fully consistent with the tenets of deliberate practice. An example with regard to echocardiography would be for the instructor to allow the resident to discover how to optimize the various views independently. The instructor would provide a rough algorithm about probe manipulations and might help the resident work through one view before letting the trainee work independently on the other views. Providing guidance is extremely important. In pure discovery learning, unguided students may not encounter the necessary circumstances or have the wherewithal to learn new principles on their own.78 This is compatible with Ericsson’s observation that routine on-the-job practice leads to stagnated abilities rather than continued improvement.10
Finally, deliberate practice can be enhanced at a more general level by cultivating metacognitive (i.e., thinking about thinking) skills. Metacognition can follow an iterative cycle: forethought or planning, performance, and critical self-evaluation to improve future performance.77 The forethought phase encompasses goal setting, strategic planning, cultivation of self-motivating beliefs, and an orientation toward learning. The performance phase includes selecting effective learning strategies, time management, help seeking, self-monitoring, and keeping records of one’s performance. The reflection phase involves self-evaluation, tracing the cause of critical events, and identification of performance aspects in need of improvement. The features of metacognition overlap with deliberate practice and can complement the technique. Anesthesiology residents will engage in metacognitive activities when they help plan educational endeavors, review goals at the start of the day, plan the educational endeavors, and reflect on the training outcome.
BARRIERS TO DELIBERATE PRACTICE IN ANESTHESIOLOGY
Unfamiliarity with Deliberate Practice
Deliberate practice strategies are not well known in anesthesia education. A PubMed search on the terms “anesth* or anaesth*” combined with “deliberate practice” recovered only 6 citations. In contrast, a similar search substituting “simulation” for “deliberate practice” yielded >3000 hits.a Thus, an information campaign may be necessary for a training program to promote routine use of the technique.
An initial step would be to provide faculty and residents with lectures and enrichment activities about deliberate practice and how it fits with training and lifelong learning. Anesthesiology attendings need instruction because only 10% to 20% of the faculty in most programs will have had formal education in teaching.79–81 Their ability to guide deliberate practice would benefit from instruction in formative feedback,82,83 assessing progress, planning teaching episodes, and accommodating instructional activity within the clinical timeframe. Articles with useful hints on clinical teaching84–91 could be circulated to faculty or used as the basis for the clinical education lectures. Clinical teaching tools, videos, and other online resources are also available.b
Providing instructors with feedback from their pupils is an effective method to promote the quality of clinical teaching. The anesthesiology program at Massachusetts General Hospital found that instructional performance improved significantly when faculty received regular quantitative individual summaries and narrative comments about teaching.92 Specific comments about deficiencies appear critical for helping teachers improve. Evaluation systems that include narrative lead to improvement, but reporting only numerical ratings to faculty is ineffective.93,94 Narrative from residents constitutes feedback, enabling faculty to enhance their clinical teaching through deliberate practice.
Problems in Selecting Daily Topics for Deliberate Practice
To lead deliberate practice, the attending anesthesiologist must address a gap in the resident’s ability with a practice activity. Identifying gaps can be difficult if the attending does not have knowledge about the trainee’s current performance, what tasks have been practiced, what issues remain, and what the resident’s next goals should be. The problem could be ameliorated if instructors wrote field notes about a resident’s educational status that could help subsequent supervisors plan teaching activities.61 Residents could help guide their own program by keeping track of their practice goals and communicating with attendings about their educational needs, examples of metacognitive skills used in pursuit of their learning.
Planning educational activities can present a challenge because much of anesthesia practice is made up of routine cases with ASA 1 and 2 patients. For example, an inguinal herniorrhaphy might not present obvious deliberate practice opportunities for residents who have handled large numbers of the operation. Anesthesia nontechnical skills, which include communication task management, teamwork, situation awareness, and decision-making ability, could be appropriate teaching topics in these situations.95 Suggestions for guiding deliberate practice on anesthesia nontechnical skills are available in the literature.96–99 Another option when the educational direction is not obvious would be to work on general topics, perhaps drawn from a list that the training program or the instructor prepared in advance. The University of California San Francisco anesthesiology training programs, where 1 of the authors worked, has used this approach in the past.
Clinical teaching must be balanced with clinical care, frequently in multiple operating rooms and at other sites in the hospital, administrative duties, and demands for scholarly activity. Competing demands can limit time for engaging residents in deliberate practice.83,92,100,101 However, strategies are available for efficient clinical teaching within the constraints of patient care responsibilities.76,90
The 5-step microskills model is also known as the “One-Minute Preceptor.”90 In steps 1 and 2, the preceptor asks the trainee to explain an observation and then to support the claim. The final steps are to deliver feedback, reinforce positive behaviors, and identify areas for improvement. In anesthesia, for example, the attending could ask the resident to propose the most likely mechanism for a modest decline in oxygen saturation. After an opinion is given, the resident would be asked to support the diagnosis with relevant information or by diagnostic tests. The attending could discuss the resident’s reasoning, point out diagnostic maneuvers that might have been missed, praise insightful statements, and talk about causes of hypoxemia during anesthesia. The microskills model is consistent with deliberate practice because it can address gaps in resident skills and it allows residents to manage a clinical episode with faculty supervision and feedback.91,102
The BID model (briefing, intraoperative teaching, and debriefing) works well for guiding deliberate practice on procedures as well as cognitive skills.76 The briefing consists of a discussion of areas where the resident needs practice and relevant learning objectives. The surrounding discussion sets the educational objectives, focuses the learner on goals, and guides the instructor’s teaching. At the beginning of a day of regional anesthesia, for example, the attending might learn that the resident has difficulty keeping the needle in view during ultrasound-guided infraclavicular blocks because of the steep angle required to reach the cords.
During the teaching phase, the attending could suggest steps that the resident should practice and ask the resident to describe the actions in his or her own words. The attending would provide ongoing feedback and encouragement as needed. Debriefing, the interactive feedback period, should include reflection on the resident’s performance, reiteration of the rules or principles that were discussed, reinforcement of the areas where improvement occurred, and summary of issues that need correction and require more practice. In the infraclavicular block example, the attending might ask the resident to summarize actions that helped in visualizing the needle. The attending could reinforce important points, give additional insight, and suggest the next goal to practice, perhaps the technique for visualizing the middle cord.
PURSUING IMPROVEMENT BY PRACTICE AFTER RESIDENCY
Although anesthesiologists need several years of experience after residency to secure a consistently superior level of performance, entry into the workforce separates physicians from academic resources and formal educational opportunities that were readily at hand during postgraduate training. Thus, continuing the journey toward expertise depends on the individual’s motivation to excel and to pursue lifelong learning.40,103,104 Opportunities for deliberate practice after residency could include work on current skill sets and new ones, workshops and simulation courses that emphasize active learning, and active methods of self-study, such as the iterative study-testing technique described earlier.
Obtaining appropriate feedback may be a challenge within the job environment. However, Ericsson10 believes that individuals approaching expert status acquire the ability to monitor, critique, and refine their own performance. For example, a budding piano virtuoso knows how a piece of music should sound, can compare their own sound to the standard, and can work to eliminate the differences. Presumably, anesthesiologists also develop self-assessment skills as they mature, satisfying part of their need for feedback. Self-assessment is straightforward when mastering a new procedure because the procedural outcome provides a modicum of feedback. Anesthesiologists could obtain additional performance measures by timing their own procedures or comparing success rates with published values. For procedures that can be recorded, such as endoscopy or ultrasound, the practitioner could review the video to identify problems in technique. Using video as part of debriefing is common in simulation courses and has been an effective source of feedback for teaching epidural anesthesia skills.105 Ericsson106 suggests that viewing video recordings of medical procedures performed by experts may also be useful as an instructional tool. Videos can capture a procedure from multiple perspectives simultaneously and may be valuable in learning uncommon procedures.106Benchmarks for excellent performance on nontechnical skills are subtler, and objective self-assessment may be more difficult. Studies suggest that physicians in the United States are inaccurate in evaluating themselves and that less skilled individuals are more likely to overestimate the quality of their performance.107,108 Thus, practicing anesthesiologists would do well to seek objective data on their work from outside sources. Anesthesiologists could ask patients after surgery for comments about the anesthesiologists’ performance. Debriefing from surgeons and nurses after an operation could be valuable. Along these lines, anesthesiologists in Denmark use surveys to elicit patient feedback about their communication skills.109
Direction by a knowledgeable mentor is important for growth. Professional athletes and entertainers receive the tutelage of coaches, even though they already perform at the highest level. Coaches provide objectivity, guide training, and recognize problems or deficiencies that a performer would not perceive alone. Thus, an anesthesiologist committed to continuous improvement might profit through feedback and guidance from a qualified adviser. Atul Gawande,110 the well-known surgeon and medical journalist, has acknowledged that he regularly asks a fellow surgeon to critique his own performance and extols the benefits of coaching.
Continuing medical education activities are avenues for improvement after residency, but the practitioner should choose wisely. Courses that present information through passive learning modes, such as lectures, do not necessarily change behavior or lead to demonstrable improvement.111 The anesthesiologist should look for events that provide active learning with opportunities for practice and feedback, such as simulation courses or workshops.63,112,113
An anesthesiologist who has been in practice for 10 to 15 years and achieved a consistent pattern of excellent performance might be inclined to adopt a relaxed training regimen. However, age-related decline in performance occurs in the later stages of a career (note the decrease in the expert performance curve after years of practice in Fig. 1). Ericsson’s research suggests that deliberate practice can forestall the loss of ability in senior professionals in piano performance114 and in elite runners.115 Thus, deliberate practice is important for improvement at the beginning of a career, for becoming an expert during the middle phase and for maintaining expertise in later years.
The primary message of this review article is that anesthesiology trainees, practicing anesthesiologists, and senior practitioners need continual deliberate practice as a means to augment and maintain their professional skill. Deliberate practice is effective because individuals are challenged in areas needing improvement, they receive feedback to correct mistakes, and they practice to the point of mastery. The training method was identified as essential in sports and musical fields, but it is also necessary for advancement in medical professions,63,116,117 including anesthesiology (Tables 2 and 3).
The 3-year U.S. anesthesiology residency does not allow a sufficient number of deliberate practice hours for residents to finish with a high level of expertise. Furthermore, anesthesiologists do not universally proceed to superior levels of performance in the years after residency (Table 1). Accordingly, we suggest that efforts are needed to augment the use of deliberate practice during residency and to inculcate anesthesiologists with the principles necessary to continue improving after residency. We suggest a number of steps, by no means an exhaustive list, that could be taken. They include training anesthesiology faculty and residents how to perform deliberate practice, methods to motivate faculty to provide the necessary supervision and feedback, and avenues for deliberate practice after residency.
These steps have a cost in time and/or money, and they require buy-in at multiple levels. The anesthesiology department must promote deliberate practice and be willing to allow the time for such efforts. Clinical instructors must commit to improving their teaching skills, to planning daily deliberate practice, and to spending sufficient time with residents for effective application of the technique. Residents must take an active role in deliberate practice work and should be diligent in using the technique for their entire careers. Finally, the practicing anesthesiologist must find ways to incorporate deliberate practice into their workplace, strive to evaluate their own performance, compare the worth of continuing medical education offerings in improving their expertise, and consider the benefit of recruiting a mentor.
In our view, the benefits of adopting deliberate practice as a training principle far outweigh the costs. Providing clinical training is one of the primary purposes of an academic anesthesiology department and should be one of the reasons an anesthesiologist chooses to join a department, rather than practicing elsewhere. Improving training quality has to be highly valued in that environment. Educational responsibility is not the sole motivation, however. Deliberate practice can yield the rewards of enhanced service and care, pride in work, and satisfaction in the practice of our demanding branch of medicine.
Name: Randolph H. Hastings, MD, PhD.
Contribution: This author helped design the study, conduct the study, analyze the data, write the manuscript, and perform the literature review.
Attestation: Randolph H. Hastings approved the final manuscript.
Name: Timothy C. Rickard, PhD.
Contribution: This author helped write the manuscript and perform the literature review.
Attestation: Timothy C. Rickard approved the final manuscript.
This manuscript was handled by: Franklin Dexter, MD, PhD.
a PubMed searches were conducted on January 11, 2014, using the terms anesth* or anaesth* and “deliberate practice”; anesth* or anaesth* and “simulation.”
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