Oversight, ownership, and the development of expertise
Part 1: Deliberate practice
In his book, Outliers: The Story of Success, Malcolm Gladwell makes the case that 10,000 hours of training is the thing that differentiates high-performance experts from everyone else. His book relied heavily on the work of K. Anders Ericsson, a psychologist who in 1993 introduced the concept of deliberate practice.
The sort of training described by Ericsson requires a process wherein trainees receive frequent, specific, actionable feedback from their coaches and mentors, reflect on the feedback, and adjust performance accordingly. If this cycle continues for a sufficiently long period of time, mastery can be developed. If the trainee just goes through the motions and puts in the time without the feedback and reflection, he or she might improve but will never reach the pinnacle of possible performance, a condition known as arrested development.
Consider the example of driving. You’d probably consider yourself a pretty good driver. More than 99.9% of the time, you are able to safely convey your vehicle and its occupants to your destination. Moreover, you’re so good at driving that you can tune the radio, take work-related phone calls, and even completely zone out for miles. You’re competent and autonomous in your driving abilities, but you're probably not a world-class expert. A Formula 1 driver, on the other hand, does not stop training when she becomes licensable, nor does she stop seeking feedback to improve even after she is declared the victor. When we train residents, we must take a similar approach; sheer volume can probably make them competent, but only deliberate practice can make them exceptional.
In medicine, every patient encounter is an opportunity for learners to refine practice until mastery is achieved, but the feedback and teaching that we as educators provide must be purposeful.
When you're working with learners, ask questions that prime them for reflection and refinement of their performance.
What would you do differently next time?
What made this patient different from others you have seen with the same condition?
What would you predict would happen if you’d done a different test, procedure, or treatment?
What is it about this case that made you think of this diagnosis rather than that one?
You missed an important finding. What steps could you take in the future to make that less likely to happen again?
Biondi EA, Varade WS, Garfunkel LC, et al. Discordance Between Resident and Faculty Perceptions of Resident Autonomy. Academic Medicine 2015;90(4):462–71.
Ericsson KA. (2016). Peak: Secrets from the New Science of Expertise. Boston : Houghton Mifflin Harcourt.
Ericsson KA. (2004). Deliberate Practice and the Acquisition and Maintenance of Expert Performance in Medicine and Related Domains. Academic Medicine, 79(10), S70–S81.
Ericsson KA, Krampe RT, Tesch-Römer, C. (1993). The role of deliberate practice in the acquisition of expert performance. Psychological Review, 100(3), 363–406.
Ericsson, KA. (2009). Development of professional expertise: toward measurement of expert performance and design of optimal learning environments. New York, Cambridge University Press.
Gladwell, M. (2008). Outliers: The story of success.