Situation awareness, caseload and thresholds of readiness for unsupervised practice

By: Olle ten Cate (@olletencate)

On my way for a dental appointment some weeks ago, I got stuck in a traffic jam. While usually it takes me 15 minutes to get there, now I arrived 30 minutes late for a one-hour appointment and anticipated a need to reschedule the placement of an molar implant (and associated costs). But the dentist was friendly, invited me to take my place, the procedure went well and 5 minutes before the scheduled end all was done. The dentist told me that, right after his implantology certification, years ago, he would plan two implants per day, now one per hour and if all goes well 30 minutes appears enough for the procedure.

The folk wisdom ‘practice makes perfect’, that seems to have occurred between his/her certification and now, has been well elaborated by Ericsson.(1) His schematic learning curves, resembling those of Dreyus & Dreyfus(2) and others, have been further substantiated by more recent studies(3).

The image above, adapted from Howard et al.(4) shows how learning may seemingly slow down at the stage of a practitioner, but as long as practice (particularly deliberate practice(1)) continues, the curve continues incrementally.

Interesting are the thresholds at certain points along the line. The licence to practice is such a threshold point, as well as the moment of formal specialty certification. Those transitions come along with a general assumption, that is, the graduate is ready for entrustment with critical tasks because of sufficient competence, and ready for hospital privileging to practice. Here, responsibilities and expectations may suddenly and steeply increase, while the learning curve itself needs time to reach high levels of proficiency and mastery.

What does it mean when a trainee is qualified as ‘ready for unsupervised practice’? If assessed to be at that level, the trainee can be entrusted with, to use the earlier example, the safe handling of molar implantations.  But does that mean readiness to handle one per hour? After a threshold for safe and high quality care, a phase is needed to establish practice routines and to gradually increase caseloads. In terms of the Dreyfus model (novice-advanced beginner-competent-proficient-expert), ‘competent’ may be that threshold, but proficient and expert stages need more practice and skill development.

In a recent NEJM podcast, Rosenbaum and Press discuss the moral injury young attendings can experience when hospital administrators force them to see more patients than the feel they can handle.(5) It is not that they cannot do the job well, but adequate attention to patients requires more time than their administration provides them with. While this hospital pressure also affects senior clinicians, junior doctors face the additional burden of high cognitive load, just because the first years of unsupervised practice require a lot more energy than when patient care routines have been well developed. Overseeing individual patient cases, combined with many others on a busy ward, requires recognition of all relevant cues and knowing how to deal with these.  

Aviation training expert Mica Endsley (chief scientist at US Airforce 2013-2015) elaborated Situation Awareness (SA) Theory as a three-level trajectory toward expertise, arguably from a threshold moment of being ‘competent’ according to the Dreyfus model. Endsley distinguishes stages or levels of Perception, Comprehension and Projection.

Perception is the recognition (visual, auditory, tactile) of relevant information cues. Endsley and her colleagues found, in their studies among pilots and doctors (6), how in aviation 76% and in hospital settings about 47% of SA errors involve the perception level. Comprehension regards how professionals combine, interpret, store, and retain relevant cues. Comprehension deficiencies were involved in 20% of aviation errors and in 39% of hospital errors. Projection is the ability to anticipate future events. Deficient projection accounted for 3% of aviation errors and 12% of hospital errors. Situation awareness in novices, says Endsley, is demanding, frequently incomplete and erroneous, while in experts SA is fast, often effortless, with great comprehension and projection.(6). The Dreyfus ‘Competent’ stage would be somewhere in between novice and expert.

The transition to a stage where competence is acknowledged  is a threshold to entrustment (by supervisors, school, community). That does not have to pertain to a full license or certification, but can also regard the summative entrustment for an EPA at level 4 (ready for unsupervised practice) on an entrustment-supervision scale before the end of training.(7) ‘Before the end of training’ may sound challenging, but it is the core purpose of time-variable, individualized competency-based (precision) training, granting autonomy only when the individual is ready for it, in a context that can still provide distant supervision or ‘sheltered independence’, as some now call this.(8) Qualification by EPAs and not all at once eases this transition.(9) On the other side of the threshold, distant supervision and a modulated case load can guard the safety of patients and that of the junior propfessional.(10) Some practitioners, e.g. some dentists, can secure that for themselves – in other cases it would be good if the hospital environment can do that for them.

About the author: Olle ten cate, PhD, is an Emeritus Profesor (AS Of October 2023) of Medical Education at University Medical Center Utrecht, the Netherlands

References

1. Ericsson KA. The Influence of Experience and Deliberate Practice on the Development of Superior Expert Performance. In: Ericsson KA, Charness N, Hoffman RR, Feltovich PJ, editors. Cambridge Handbook of Expertise and Expert Performance. 1st ed. Cambridge: Cambridge University Press; 2006. p. 685–705.
2. Dreyfus HL, Dreyfus SE. Mind over Machine. New York: Free Press; 1986.
3. Howard NM, Cook DA, Hatala R, Pusic MV. Learning curves in health professions education simulation research: A systematic review. Simul Healthc. 2021 Apr 1;16(2):128–35.
4. Howard N, Pusic M. The metacognitive competency: becoming a master adaptive learner. In: Kalet A, Chou CL, editors. Remediation in Medical Education: A Mid-Course Correction. Cham: Springer International Publishing; 2023. p. 39–51.
5. Injured, not sidelined: NOS episode 2.10. N Engl J Med. 2024 Apr 18;390(15):e37.
6. Endsley MR. Expertise and situation awareness. In: Ericsson KA, Hoffman RR, Kozbelt A, Williams AM, editors. The Cambridge Handbook of Expertise and Expert Performance. Cambridge University Press; 2018. p. 714–42.
7. ten Cate O, Schwartz A, Chen HC. Assessing Trainees and Making Entrustment Decisions: On the Nature and Use of Entrustment-Supervision Scales. Acad Med. 2020 Nov;95(11):1662–9.
8. Goldhamer MEJ, Pusic MV, Nadel ES, Co JPT, Weinstein DF. Promotion in Place: A Model for Competency-Based, Time-Variable Graduate Medical Education. Acad Med. 2024 May 1;99(5):518–23.
9. ten Cate O, Turner DA, Pusic MV, Schumacher DJ. Chapter 16. Entrustable professional activities and transitions across the continuum of training and practice. In: ten Cate O, Burch VC, Chen HC, Chou FC, editors. Entrustable Professional Activities and Entrustment Decision-Making in Health Professions Education [forthcoming]. London, UK: Ubiquity Press; 2024.
10. Turner DA, Schwartz A, Carraccio C, Herman B, Weiss P, Baffa JM, et al. Continued supervision for the common pediatric subspecialty entrustable professional activities may be needed following fellowship graduation. Acad Med. 2021 Jul 1;96(7S):S22–8.

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