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Restricted Duty Hours + Deliberate Practice = Improved Education?

By Jonathan Sherbino (@sherbino)

My colleague, Geoff Norman and I recently published an editorial outlining some of the issues involving research on diagnostic reasoning.   The suggested conclusions from the editorial may have a broader appeal to the HPE community.

In an age of restricted resident duty hours and increasing attention to education practices that ensure patient safety, how do we optimize learning?  (To explore the impact of restricted duty hours on written test scores, see this KeyLIME podcast For the impact of surgical trainees on patient outcomes, check out this KeyLIME podcast.

Ericsson excellently describes the education theory behind deliberate practice (DP) here.  A more condensed version from Duvivier et. al. identify the key components of DP.

DP has wonderful implications for simulation.  In fact, mastery learning (a marker of quality in simulation education) is closely related to DP, with the distinction that a “large” skill can be divided into sub-skills that sequentially build on each other.  In the simulated environment, a learner can practice at a tailored pace to master all of the connected skills before performing a similar task in clinical practice.

However, there is a danger with DP as it relates to cognitive (and not psychomotor) tasks.  You could imagine a simulated databank of pediatric ankle xrays, designed to teach the diagnosis of MSK injuries, might distort the prevalence of injury or the representativeness of xray features, in an attempt to provide a comprehensive set of images.  (For a very cool study… that doesn’t make this error… check out this study by Pusic et al.) Therefore, simulated datasets used for DP should be ecologically and epidemiologically valid samples. This combination of DP with appropriate representative samples has been labeled mixed practice.

Rather than relying on ad hoc exposures in the (increasingly limited) clinical environment with the attendant issues of patient safety, mixed practice provides accelerate learning in simulated environments. However, mixed practice should only serve as a (foundation?) introduction into the complexities of authentic clinical practice.  After all, learning in the clinical environment is the most important element of health professions education.

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