Disrupting the OK plateau

By Warwick Isaacson (@WarwickIsaacson) & Victoria Brazil (@SocraticEM)

The Emergency Department is busy. While typing your admission plan for another patient an ECG appears in your peripheral vision. “Could you take a quick look at this, it’s for a 60 yr old lady at triage.” asks the intern, “..she thinks it was just some reflux, feels fine now and wants to leave”. The ECG looks OK… the machine agrees. With a squiggle of your pen the “normal ECG” disappears, allowing your attention to return to the keyboard.

The next morning your department head taps you on the shoulder. “do you remember that ECG you signed off on yesterday? The patient returned later that night with a STEMI. I think there were some subtle signs on her initial ECG that could have allowed us to do better…”. In reflecting on the error, you can’t help but agree… your slow typing speed has been a longstanding issue.

Hang on… In a blog about education and performance where does typing speed fit into the equation? Bear with me as we use the example at our fingertips to provide some insight on skill acquisition, the “OK Plateau” and the use of teaching to disrupt the atrophy of expertise.

How fast is your typing speed? Average, above? How about that of some of your colleagues. I know in my institution there are some that still embrace the two-finger technique. Given the time critical nature of medicine, the necessity of typing, the frequency with which it is performed and the accessibility of tools to improve, why don’t these caring, intelligent, motivated and driven individuals strive to do better?

It is because they have reached their “Ok Plateau”.

To understand the OK plateau it is helpful to break down the stages of skill acquisition.

Stage 1: The cognitive phase: Every key on the keyboard is new, visual scanning is required to find letters and numbers, punctuation is annoying and capitalising letters is an extravagant two-step process that some concede is just too difficult.

Stage 2: The associative phase: As familiarity with the keys grows the use of touch-typing techniques is explored. Some will happily embrace the use of typing programs to dictate which fingers are allowed on individual keys. The frustrating compromise of technique versus speed will see some break from the recommended fingering early to devise their own style. There will be a variable adoption of the available keyboard shortcuts, punctuation and formatting options. As the assimilation of these microtasks strengthens typing speed and accuracy will increase.

Stage 3: The autonomous phase: Here typing becomes automatic. The cognitive load applied to the skill is minimal with the mind free to focus on content and other ongoing tasks. This autonomous phase has been nicely described as the “OK Plateau” where you have reached a point you are satisfied with, and no longer are paying attention to, the acquisition or improvement of the skill.

Figure 1. Stages of skill acquisition. Adapted from Fitts and Posner’s (1967) model 1

The stages of skill acquisition are summarised in Figure 1. With increasing time performing a task (experience) the cognitive effort or “bandwidth” required to perform it decreases freeing up cognitive load for other tasks.

There is both beauty and danger in the OK plateau.

The OK plateau provides us with comfort and predictability but – as with anything that feels easy – there is a darker side. Reaching the OK plateau too early can truncate the necessary and desirable difficulties required to excel….

The important question is what separates the excellent from the OK?

Performance science has undergone a renaissance, led by the work of Professor K. Anders Ericsson. By studying people at the top of their fields, he demonstrated that while genetics and opportunity play a role, it is an individual’s preparedness to take themselves out of their comfort zone to embrace the desirable difficulty2,3 of purposeful practice that sets them apart.

Exceptional performance is based on exceptional practice. Success is not a function of talent and experience but an individual’s ability to embrace defined and specific goals, to study failure and seek feedback. The high performing outliers never progress further than Stage 1 and Stage 2 of skill acquisition – they remain in the cognitive and associative stages that evade the ‘stagnation of automation’.

“Deliberate practice takes place outside one’s comfort zone and requires the student to constantly try things that are just beyond their current abilities” (Ericsson)

That said, there is a murkier component of the performance algorithm.  The line separating the healthy application of ‘grit’ from an unhealthy quest for perfection can be blurred. A growing body of evidence on physician burnout has shown an unhealthy perfectionism is counterproductive to global performance. Most of us know (or are) that perfectionist colleague who has aimed to elevate their OK plateau in so many areas as to stifle real progress in any of them.

“Perfect is the enemy of good” (Voltaire)

So let’s return to our struggle with the keyboard and ECG to replay the interaction…

An ECG appears in your peripheral vision… gingerly held by the nervous intern.

Your frustration with typing is suddenly lifted. You smile in the knowledge that you’ve just been gifted an opportunity to teach… an altruistic forcing function that will combat the atrophy of your ECG interpretation skills and transcend the OK plateau.

“I’ll share what I am thinking when I look at this ECG… First, I’m going take a systematic approach examine the rate, rhythm, axis, intervals and morphology. This looks OK on gross inspection and I can see that the machine has agreed with their “Normal ECG” interpretation” (We are back in Stage 1 – the cognitive phase)

“However I know that females are overrepresented in the group of patients with atypical ischaemic chest pain. That is why I want to look a little closer at this ECG for subtle signs of ischaemia. (Hello Stage 2 – the association phase)

“I can see here there is some flattening of the ST segments and this morphology can be an early sign of ischaemia. This patient needs to stay… Can I also ask, did my coaching on ECG interpretation make sense and can I clarify or expand on anything more effectively?” (reflecting on performance and seeking feedback to improve)

The next morning your director taps you on the shoulder… “One of the interns was impressed with your ECG interpretation and willingness to teach.”

The attention required to improve your typing skills can wait…

Further reading:

  1. Philip Alexander Furley & Daniel Memmert (2010) The role of working memory in sport, International Review of Sport and Exercise Psychology, 3:2, 171-194
  2. Peak: secrets from the new science of expertise. K. Anders Ericsson, Robert Pool 2016
  3. https://freakonomics.com/podcast/peak/
  4. https://www.brainpickings.org/2013/10/17/ok-plateau/


About the co-author: Warwick Isaacson is an emergency physician and Education Fellow at the Gold Coast Health Service in Australia.

The views and opinions expressed in this post are those of the author(s) and do not necessarily reflect the official policy or position of The Royal College of Physicians and Surgeons of Canada. For more details on our site disclaimers, please see our ‘About’ page