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Deliberate Practice for Achieving and Maintaining Expertise in Anesthesiology Randolph H. Hastings, MD, PhD,* and Timothy C. Rickard, PhD† For the dedicated anesthesiologist, a high level of expertise is needed to deliver good care to patients and to provide excellent service to surgeons, anesthesia colleagues, and others. Expertise helps the anesthesiologist recover from difficult situations and generally makes the practice run more effectively. Expertise also contributes to quality of life through higher selfesteem and long-term career satisfaction. We begin by reviewing the attributes that characterize expert performance and discussing how a specific training format, known as deliberate practice, contributes to acquisition and maintenance of expertise. Deliberate practice involves rehearsal of specific tasks to mastery, ideally under the eye of a mentor to provide feedback. This amounts to an orchestrated effort to improve that enables trainees to progress to expert levels of performance. With few exceptions, people who become recognized experts have pursued deliberate practice on the order of 4 hours per day for 10 to 15 years. In contrast, those who practice their profession in a rote manner see their skills plateau well below the level of top performers. Anesthesiology instruction with attending supervision provides all of the necessary components for deliberate practice, and it can be effective in anesthesia. Using deliberate practice in teaching requires organization in selecting training topics, effort in challenging students to excel, and skill in providing feedback. In this article, we discuss how educational programs can implement deliberate practice in anesthesiology training, review resources for instructors, and suggest how anesthesiologists can continue the practice after residency. (Anesth Analg 2015;120:449–59)
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eveloping expertise is an important goal in any line of work. The desire to be good at one’s work grows out of the aspiration to lead a virtuous and productive life. For a dedicated anesthesiologist, performing at a high level means delivering good care to patients and providing excellent service to surgeons, anesthesia colleagues, other providers, and the hospital. Expertise may help the anesthesiologist reduce the chance of complications1 and assist in recovering from difficult situations.2–4 It is generally characterized by an organized approach to performing anesthesiology.5 Being an expert in one’s profession leads to higher self-esteem and long-term career satisfaction.6–8 It could also increase job security. Reliable, continued improvement in skills and performance results from deliberate practice, a training method in which the learner is (1) given a task exceeding his or her current skill level, (2) motivated to practice extensively and improve, (3) provided with comprehensive and effective feedback, and (4) prompted to reflect on the learning experience.9 Once a goal has been met, the trainee advances to a more difficult task. Deliberate practice was first identified as the critical factor in achieving expertise in motor skill domains,10 and the steps may be familiar to people who have been involved with organized sports, learning music, or other performance arts. The method is also effective in other fields, including medicine.11 From the *Anesthesiology Service, VA San Diego Healthcare System, San Diego, California; and †Department of Psychology, UC San Diego, La Jolla, California. Accepted for publication September 11, 2014. Funding: Salary from VASDHS and UCSD. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Randolph H. Hastings, MD, PhD, Anesthesiology Service, VA San Diego Healthcare System, 3350 La Jolla Village Dr. 125, San Diego, CA 92161. Address e-mail to [email protected]. Copyright © 2015 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000000526
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The goals of this article are to review the attributes that characterize expert performance and to discuss how deliberate practice cultivates and maintains individual expertise. It will review the general topic of expertise from the perspectives of education and psychology and then describe specific applications in anesthesiology. We will also discuss how training programs, continuing education modalities, and the individual practitioner can use deliberate practice to promote that goal.
CHARACTERIZING AND DEVELOPING EXPERT PERFORMANCE Distinguishing Features of Experts
Expertise may be manifest qualitatively by superior perceptual, motor, and/or cognitive skills.12 For instance, experts in typing, tennis, and other pursuits are better than nonexperts in anticipating future movements controlling actions. Chess experts have a better memory of mid-game chess piece positions that they use to identify the best moves. According to K. Anders Ericsson, an authority on expert performance, consistently superior performance is the common characteristic of expertise in any field. Ericsson et al.12 suggest that expertise level can be quantified with standardized tests, such as high-fidelity simulations; examples are presented later in this article.
DEVELOPING EXPERT PERFORMANCE Can High Level Expertise Be Nurtured?
Since the time of the ancient Greeks, numerous philosophers, social scientists, and psychologists have debated whether the capacity for elite performance is inborn or predominantly learned.13 If innate ability were a required prerequisite for high-level achievement, it would be futile to seek educational methods that would foster expert performance in every pupil. The psychologist Benjamin Bloom conducted extensive field research on the foundations of www.anesthesia-analgesia.org
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E review article expertise. After reviewing the early lives of >120 star performers in the arts, sports, and scientific fields, he concluded that achieving excellence depended on hard work and training rather than exceptional native ability alone.14 Bloom’s observational work is supported by controlled experiments showing that proper training can lead unselected people with normal baseline abilities to amazing accomplishments,12 such as memorizing random strings of 80 or more digits15 or performing thousands of pushups in 1 sitting.16 Thus, it would be reasonable to expect hard work and sophisticated training methods to boost anesthesia performance to high levels. The section below discusses the training requirements for acquiring expertise and contrasts the results that may be expected from routine practice versus deliberate practice. The sections that follow review the evidence that deliberate practice can improve learning in anesthesiology.
Attaining Expert Performance Through Deliberate Practice
Humans develop the ability to perform commonplace activities, such as tying shoes or riding a bicycle after a relatively short period of simple practice.12 Performance plateaus at an acceptable level (lowest curve in Fig. 1 adapted from Ericsson’s work10) because further improvement carries little benefit. Professional and competitive domains require higher level performance, and skill acquisition must continue for a longer period of time, as shown by the middle curve in the same figure. However, acceptability can still blunt the drive to improve, so routine repetition of complex tasks does not inevitably lead to outstanding performance.17–20 Thus, recreational athletes peak at an acceptable, modest playing ability, and choir members become proficient in singing to local audiences, but nothing more. On the other hand, learners who use deliberate practice in their training can experience prolonged improvement throughout most of a career (uppermost curve in Fig. 110).
To understand why routine practice does not allow improvement to continue indefinitely, consider the benefit a basketball player would receive by only practicing shooting baskets during games, an example of routine performance. He or she would have 1 chance for each shot, no chance to repeat the shot until it worked, no immediate feedback from the coach, and no opportunity to reflect on performance. Outside of competition, the player could engage in deliberate practice by working repeatedly on mastering specific shots that may only arise a few times per game, varying distance, angle, or defensive pressure and receiving feedback from a coach.21 The game environment limits opportunity for improvement, while deliberate practice facilitates it. How much deliberate practice is needed to reach expert performance levels? In a classic study, Simon and Chase22 observed that at least 10,000 hours of self-reported practice over 10 years or more were necessary for chess players to achieve elite performance in competitive play against grandmasters. Accumulating 10,000 hours of deliberate practice over 10 to 15 years14 appears to be linked consistently to development of exceptional performance across multiple disparate skill domains, including music, sports, and science.11,23,24
EXPERTISE IN ANESTHESIOLOGY Does Anesthesiology Residency Produce Expertise?
We would have reasonable confidence that anesthesiology residents would achieve consistently superior performance if residency included 10,000 hours of deliberate practice,5 the number necessary for expertise in other disciplines.11,22–24 Residents in the authors’ anesthesiology program work 270 days per year. Most humans are limited to a maximum of about 4 hours of deliberate practice per day because of the intense effort required to combine practice and close attention to feedback.9 Thus, about 3240 hours of deliberate practice could occur over the course of a 3-year residency if all opportunities were used. This is slightly less than one-third of the 10,000-hour milestone for expertise. By these figures, anesthesiology trainees would be far from achieving highlevel performance at the conclusion of residency, even under the best circumstances. Several additional years of hard work would be required to reach the 10,000-hour mark and the corresponding high-level performance,9,14,22,23 amounting to 7 to 12 years and an age in the mid-30s to early 40s.
Do Anesthesiologists Continue Improving After Residency? Figure 1. The performance trajectory for people learning new skills can follow various courses. Individuals generally develop adequate expertise in an everyday skill after a short training period, 50 hours or less. Actions become automatic at that point and performance plateaus. In contrast, people who pursue a competitive or highly technical professional activity continue to improve for a longer period, but performance will eventually arrest if training occurs in a rote manner. In contrast, individuals who follow an intensive training method called deliberate practice will improve for a longer, possibly indefinite period and reach an expert level of performance after 10 to 15 years of training. The deliberate practice strategy is unique in actively seeking improvement (see text). If the professional ceases deliberate practice, their improvement will cease and their performance will arrest at a lower level.10 Used with permission from Taylor & Francis Ltd, www.tandfonline.com.
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A relevant question is whether anesthesiologists routinely proceed to high-level performance after residency. Simulations involving anesthetic crises are appropriate models for testing high-level anesthesiology performance because managing critical incidents requires skills that numerous authorities associate with anesthesiology expertise.25–31 Henrichs et al.32 used quantitative assessment tools to evaluate how 35 practicing anesthesiologists (2–26 years in practice) performed with 8 scripted critical intraoperative events. In advance, the authors had suggested that accomplished anesthesiologists should perform at least 75% of the steps considered key for appropriate management. In fact,
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subjects accomplished 67% ± 12% of the key steps overall. Performance was approximately 60% for myocardial ischemia, blocked endotracheal tube, and total spinal scenarios and 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 PubMed searches were conducted on January 11, 2014, using the terms anesth* or anaesth* and “deliberate practice”; anesth* or anaesth* and “simulation.”
a
b
www.practicaldoc.ca.
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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.
Time Pressure
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 “OneMinute 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
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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
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E review article 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.
CONCLUSIONS
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.
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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.E DISCLOSURES
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. REFERENCES 1. Smith AF, Arfanis K. “Sixth sense” for patient safety. Br J Anaesth 2013;110:167–9 2. Gaba DM. Anaesthesiology as a model for patient safety in health care. BMJ 2000;320:785–8
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E review article training improves physicians’ performance in patient care in high-stakes clinical setting of cardiac surgery. Anesthesiology 2010;112:985–92 54. Ashurst N, Rout CC, Rocke DA, Gouws E. Use of a mechanical simulator for training in applying cricoid pressure. Br J Anaesth 1996;77:468–72 55. Park CS, Rochlen LR, Yaghmour E, Higgins N, Bauchat JR, Wojciechowski KG, Sullivan JT, McCarthy RJ. Acquisition of critical intraoperative event management skills in novice anesthesiology residents by using high-fidelity simulation-based training. Anesthesiology 2010;112:202–11 56. Steadman RH. Improving on reality: can simulation facilitate practice change? Anesthesiology 2010;112:775–6 57. Baker PA, Weller JM, Greenland KB, Riley RH, Merry AF. Education in airway management. Anaesthesia 2011;66 Suppl 2:101–11 58. Curry S. The adult learner. Int Anesthesiol Clin 2008;46:17–26 59. de Oliveira Filho GR, Schonhorst L. Problem-based learning implementation in an intensive course of anaesthesiology: a preliminary report on residents’ cognitive performance and perceptions of the educational environment. Med Teach 2005;27:382–4 60. Rodriguez-Paz JM, Kennedy M, Salas E, Wu AW, Sexton JB, Hunt EA, Pronovost PJ. Beyond “see one, do one, teach one”: toward a different training paradigm. Postgrad Med J 2009;85:244–9 61. Houben KW, van den Hombergh CL, Stalmeijer RE, Scherpbier AJ, Marcus MA. New training strategies for anaesthesia residents. Curr Opin Anaesthesiol 2011;24:682–6 62. McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. Effect of practice on standardised learning outcomes in simulationbased medical education. Med Educ 2006;40:792–7 63. McGaghie WC, Siddall VJ, Mazmanian PE, Myers J. Lessons for continuing medical education from simulation research in undergraduate and graduate medical education. Chest 2009;135:62S–8S 64. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 2005;27:10–28 65. Stackhouse RA. Fiberoptic airway management. Anesthesiol Clin North America 2002;20:933–51 66. Barsuk JH, Cohen ER, Caprio T, McGaghie WC, Simuni T, Wayne DB. Simulation-based education with mastery learning improves residents’ lumbar puncture skills. Neurology 2012;79:132–7 67. Barsuk JH, McGaghie WC, Cohen ER, O’Leary KJ, Wayne DB. Simulation-based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit. Crit Care Med 2009;37:2697–701 68. Dunlosky J. Strengthening the student toolbox. Am Educator 2013;37:12–21 69. Roediger HL, Karpicke JD. The power of testing memory: basic research and implications for educational practice. Persp Psychol Pract 2006;1:181–210 70. Carpenter SK, Pashler H, Vul E. What types of learning are enhanced by a cued recall test? Psychon Bull Rev 2006;13:826–30 71. Vojdanoska M, Cranney J, Newell BR. The testing effect: the role of feedback and collaboration in a tertiary classroom setting. Appl Cog Psychol 2010;24:1183–95 72. Cepeda NJ, Pashler H, Vul E, Wixted JT, Rohrer D. Distributed practice in verbal recall tasks: a review and quantitative synthesis. Psychol Bull 2006;132:354–80 73. Gerbier E, Toppino TC, Koenig O. Optimising retention through multiple study opportunities over days: the benefit of an expanding schedule of repetitions. Memory 2014;12:1–12 74. Rohrer D, Taylor K. The shuffling of mathematical problems improves learning. Instr Sci 2007;35:481–98 75. Brooks AL, Aldrich PJ, Tenenbaum HR. Does discovery-based instruction enhance learning? J Educ Psychol 2011;103:1–18 76. Roberts NK, Williams RG, Kim MJ, Dunnington GL. The briefing, intraoperative teaching, debriefing model for teaching in the operating room. J Am Coll Surg 2009;208:299–303 77. Zimmerman BJ. Investigating self-regulation and motivation: historical background, methodological developments and future prospects. Am Educ Res 2008;45:166–83
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78. Mayer RE. Should there be a three-strikes rule against pure discovery learning? The case for guided methods of instruction. Am Psychol 2004;59:14–9 79. Macario A, Edler A, Pearl R. Training attendings to be expert teachers: the Stanford Anesthesia Teaching Scholars program. J Clin Anesth 2008;20:241–2 80. Kiki M, Lombarts JMH, Bucx MJL, Arah OA. Development of a system for the evaluation of the teaching qualities of anesthesiology faculty. Anesthesiology 2009;111:709–16 81. Schwartz AJ. Resident/fellow evaluation of clinical teaching: an essential ingredient of effective teacher development and educational planning. Anesthesiology 2010;113:516–7 82. Steinert Y, Mann K, Centeno A, Dolmans D, Spencer J, Gelula M, Prideaux D. A systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education: BEME Guide No. 8. Med Teach 2006;28:497–526 83. De Oliveira GS Jr, Rahmani R, Fitzgerald PC, Chang R, McCarthy RJ. The association between frequency of selfreported medical errors and anesthesia trainee supervision: a survey of United States anesthesiology residents-in-training. Anesth Analg 2013;116:892–7 84. Lake FR, Ryan G. Teaching on the run tips 13: being a good supervisor–preventing problems. Med J Aust 2006;184:414–5 85. Lake FR, Hamdorf JM. Teaching on the run tips 6: determining competence. Med J Aust 2004;181:502–3 86. Lake FR, Hamdorf JM. Teaching on the run tips 5: teaching a skill. Med J Aust 2004;181:327–8 87. Lake FR, Ryan G. Teaching on the run tips 3: planning a teaching episode. Med J Aust 2004;180:643–4 88. Lake FR, Vickery AW. Teaching on the run tips 14: teaching in ambulatory care. Med J Aust 2006;185:166–7 89. Gordon J. ABC of learning and teaching in medicine. One to one teaching and feedback. Br Med J 2005;326:543–5 90. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills” model of clinical teaching. J Am Board Fam Pract 1992;5:419–24 91. Gallagher P, Tweed M, Hanna S, Winter H, Hoare K. Developing the one-minute preceptor. Clin Teach 2012;9:358–62 92. Baker K. Clinical teaching improves with resident evaluation and feedback. Anesthesiology 2010;113:693–703 93. Tiberius RG, Sackin HD, Slingerland JM, Jubas K, Bell M, Matlow A. The influence of student evaluative feedback on the improvement of clinical teaching. J Higher Ed 1989;60:665–81 94. Cohan RH, Dunnick NR, Blane CE, Fitzgerald JT. Improvement of faculty teaching performance: efficacy of resident evaluations. Acad Radiol 1996;3:63–7 95. Glavin RJ. Excellence in anesthesiology: the role of nontechnical skills. Anesthesiology 2009;110:201–3 96. Wachtel RE, Dexter F. Curriculum providing cognitive knowledge and problem-solving skills for anesthesia systems-based practice. J Grad Med Educ 2010;2:624–32 97. Gaba DM. Crisis resource management and teamwork training in anaesthesia. Br J Anaesth 2010;105:3–6 98. Schulz CM, Endsley MR, Kochs EF, Gelb AW, Wagner KJ. Situation awareness in anesthesia: concept and research. Anesthesiology 2013;118:729–42 99. Gaiser RR. The teaching of professionalism during residency: why it is failing and a suggestion to improve its success. Anesth Analg 2009;108:948–54 100. Hindman BJ, Dexter F, Kreiter CD, Wachtel RE. Determinants, associations, and psychometric properties of resident assessments of anesthesiologist operating room supervision. Anesth Analg 2013;116:1342–51 101. Haydar B, Charnin J, Voepel-Lewis T, Baker K. Resident characterization of better-than- and worse-than-average clinical teaching. Anesthesiology 2014;120:120–8 102. Wong A. Teaching, learning, and the pursuit of excellence in anesthesia education. Can J Anesth 2012;59:171–81 103. de Oliveira Filho GR, Vieira JE. The relationship of learning environment, quality of life, and study strategies measures to anesthesiology resident academic performance. Anesth Analg 2007;104:1467–72
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104. Smith A, Goodwin D, Mort M, Pope C. Expertise in practice: an ethnographic study exploring acquisition and use of knowledge in anaesthesia. Br J Anaesth 2003;91:319–28 105. Birnbach DJ, Santos AC, Bourlier RA, Meadows WE, Datta S, Stein DJ, Kuroda MM, Thys DM. The effectiveness of video technology as an adjunct to teach and evaluate epidural anesthesia performance skills. Anesthesiology 2002;96:5–9 106. Ericsson KA. Necessity is the mother of invention: video recording firsthand perspectives of critical medical procedures to make simulated training more effective. Acad Med 2014;89:17–20 107. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA 2006;296:1094–102 108. Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Pers Soc Psychol 1999;77:1121–34 109. Ringsted C, Østergaard D, van der Vleuten CP. Implementation of a formal in-training assessment programme in anaesthesiology and preliminary results of acceptability. Acta Anaesthesiol Scand 2003;47:1196–203 110. Gawande A. Top athletes and singers have coaches. Should you? New Yorker. October 3, 2011:9
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111. Davis DA, Galbraith R. Continuing medical education effect on practice performance. Chest 2009;135:42S–8S 112. Levine AI, Flynn BC, Bryson EO, Demaria S Jr. Simulationbased Maintenance of Certification in Anesthesiology (MOCA) course optimization: use of multi-modality educational activities. J Clin Anesth 2012;24:68–74 113. McIvor W, Burden A, Weinger MB, Steadman R. Simulation for maintenance of certification in anesthesiology: the first two years. J Contin Educ Health Prof 2012;32:236–42 114. Krampe RT, Ericsson KA. Maintaining excellence: deliberate practice and elite performance in young and older pianists. J Exp Psychol Gen 1996;125:331–59 115. Young BW, Medic N, Weir PL, Starkes JL. Explaining performance in elite middle-aged runners: contributions from age and from ongoing and past training factors. J Sport Exerc Psychol 2008;30:737–54 116. van de Wiel MW, Van den Bossche P, Janssen S, Jossberger H. Exploring deliberate practice in medicine: how do physicians learn in the workplace? Adv Health Sci Educ Theory Pract 2011;16:81–95 117. Regehr G, Mylopoulos M. Maintaining competence in the field: learning about practice, through practice, in practice. J Contin Educ Health Prof 2008;28 Suppl 1:S19–23
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Deliberate Practice for Achieving and Maintaining Expertise in Anesthesiology Randolph H. Hastings, MD, PhD,* and Timothy C. Rickard, PhD† For the dedicated anesthesiologist, a high level of expertise is needed to deliver good care to patients and to provide excellent service to surgeons, anesthesia colleagues, and others. Expertise helps the anesthesiologist recover from difficult situations and generally makes the practice run more effectively. Expertise also contributes to quality of life through higher selfesteem and long-term career satisfaction. We begin by reviewing the attributes that characterize expert performance and discussing how a specific training format, known as deliberate practice, contributes to acquisition and maintenance of expertise. Deliberate practice involves rehearsal of specific tasks to mastery, ideally under the eye of a mentor to provide feedback. This amounts to an orchestrated effort to improve that enables trainees to progress to expert levels of performance. With few exceptions, people who become recognized experts have pursued deliberate practice on the order of 4 hours per day for 10 to 15 years. In contrast, those who practice their profession in a rote manner see their skills plateau well below the level of top performers. Anesthesiology instruction with attending supervision provides all of the necessary components for deliberate practice, and it can be effective in anesthesia. Using deliberate practice in teaching requires organization in selecting training topics, effort in challenging students to excel, and skill in providing feedback. In this article, we discuss how educational programs can implement deliberate practice in anesthesiology training, review resources for instructors, and suggest how anesthesiologists can continue the practice after residency. (Anesth Analg 2015;120:449–59)
D
eveloping expertise is an important goal in any line of work. The desire to be good at one’s work grows out of the aspiration to lead a virtuous and productive life. For a dedicated anesthesiologist, performing at a high level means delivering good care to patients and providing excellent service to surgeons, anesthesia colleagues, other providers, and the hospital. Expertise may help the anesthesiologist reduce the chance of complications1 and assist in recovering from difficult situations.2–4 It is generally characterized by an organized approach to performing anesthesiology.5 Being an expert in one’s profession leads to higher self-esteem and long-term career satisfaction.6–8 It could also increase job security. Reliable, continued improvement in skills and performance results from deliberate practice, a training method in which the learner is (1) given a task exceeding his or her current skill level, (2) motivated to practice extensively and improve, (3) provided with comprehensive and effective feedback, and (4) prompted to reflect on the learning experience.9 Once a goal has been met, the trainee advances to a more difficult task. Deliberate practice was first identified as the critical factor in achieving expertise in motor skill domains,10 and the steps may be familiar to people who have been involved with organized sports, learning music, or other performance arts. The method is also effective in other fields, including medicine.11 From the *Anesthesiology Service, VA San Diego Healthcare System, San Diego, California; and †Department of Psychology, UC San Diego, La Jolla, California. Accepted for publication September 11, 2014. Funding: Salary from VASDHS and UCSD. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Randolph H. Hastings, MD, PhD, Anesthesiology Service, VA San Diego Healthcare System, 3350 La Jolla Village Dr. 125, San Diego, CA 92161. Address e-mail to [email protected]. Copyright © 2015 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000000526
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The goals of this article are to review the attributes that characterize expert performance and to discuss how deliberate practice cultivates and maintains individual expertise. It will review the general topic of expertise from the perspectives of education and psychology and then describe specific applications in anesthesiology. We will also discuss how training programs, continuing education modalities, and the individual practitioner can use deliberate practice to promote that goal.
CHARACTERIZING AND DEVELOPING EXPERT PERFORMANCE Distinguishing Features of Experts
Expertise may be manifest qualitatively by superior perceptual, motor, and/or cognitive skills.12 For instance, experts in typing, tennis, and other pursuits are better than nonexperts in anticipating future movements controlling actions. Chess experts have a better memory of mid-game chess piece positions that they use to identify the best moves. According to K. Anders Ericsson, an authority on expert performance, consistently superior performance is the common characteristic of expertise in any field. Ericsson et al.12 suggest that expertise level can be quantified with standardized tests, such as high-fidelity simulations; examples are presented later in this article.
DEVELOPING EXPERT PERFORMANCE Can High Level Expertise Be Nurtured?
Since the time of the ancient Greeks, numerous philosophers, social scientists, and psychologists have debated whether the capacity for elite performance is inborn or predominantly learned.13 If innate ability were a required prerequisite for high-level achievement, it would be futile to seek educational methods that would foster expert performance in every pupil. The psychologist Benjamin Bloom conducted extensive field research on the foundations of www.anesthesia-analgesia.org
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E review article expertise. After reviewing the early lives of >120 star performers in the arts, sports, and scientific fields, he concluded that achieving excellence depended on hard work and training rather than exceptional native ability alone.14 Bloom’s observational work is supported by controlled experiments showing that proper training can lead unselected people with normal baseline abilities to amazing accomplishments,12 such as memorizing random strings of 80 or more digits15 or performing thousands of pushups in 1 sitting.16 Thus, it would be reasonable to expect hard work and sophisticated training methods to boost anesthesia performance to high levels. The section below discusses the training requirements for acquiring expertise and contrasts the results that may be expected from routine practice versus deliberate practice. The sections that follow review the evidence that deliberate practice can improve learning in anesthesiology.
Attaining Expert Performance Through Deliberate Practice
Humans develop the ability to perform commonplace activities, such as tying shoes or riding a bicycle after a relatively short period of simple practice.12 Performance plateaus at an acceptable level (lowest curve in Fig. 1 adapted from Ericsson’s work10) because further improvement carries little benefit. Professional and competitive domains require higher level performance, and skill acquisition must continue for a longer period of time, as shown by the middle curve in the same figure. However, acceptability can still blunt the drive to improve, so routine repetition of complex tasks does not inevitably lead to outstanding performance.17–20 Thus, recreational athletes peak at an acceptable, modest playing ability, and choir members become proficient in singing to local audiences, but nothing more. On the other hand, learners who use deliberate practice in their training can experience prolonged improvement throughout most of a career (uppermost curve in Fig. 110).
To understand why routine practice does not allow improvement to continue indefinitely, consider the benefit a basketball player would receive by only practicing shooting baskets during games, an example of routine performance. He or she would have 1 chance for each shot, no chance to repeat the shot until it worked, no immediate feedback from the coach, and no opportunity to reflect on performance. Outside of competition, the player could engage in deliberate practice by working repeatedly on mastering specific shots that may only arise a few times per game, varying distance, angle, or defensive pressure and receiving feedback from a coach.21 The game environment limits opportunity for improvement, while deliberate practice facilitates it. How much deliberate practice is needed to reach expert performance levels? In a classic study, Simon and Chase22 observed that at least 10,000 hours of self-reported practice over 10 years or more were necessary for chess players to achieve elite performance in competitive play against grandmasters. Accumulating 10,000 hours of deliberate practice over 10 to 15 years14 appears to be linked consistently to development of exceptional performance across multiple disparate skill domains, including music, sports, and science.11,23,24
EXPERTISE IN ANESTHESIOLOGY Does Anesthesiology Residency Produce Expertise?
We would have reasonable confidence that anesthesiology residents would achieve consistently superior performance if residency included 10,000 hours of deliberate practice,5 the number necessary for expertise in other disciplines.11,22–24 Residents in the authors’ anesthesiology program work 270 days per year. Most humans are limited to a maximum of about 4 hours of deliberate practice per day because of the intense effort required to combine practice and close attention to feedback.9 Thus, about 3240 hours of deliberate practice could occur over the course of a 3-year residency if all opportunities were used. This is slightly less than one-third of the 10,000-hour milestone for expertise. By these figures, anesthesiology trainees would be far from achieving highlevel performance at the conclusion of residency, even under the best circumstances. Several additional years of hard work would be required to reach the 10,000-hour mark and the corresponding high-level performance,9,14,22,23 amounting to 7 to 12 years and an age in the mid-30s to early 40s.
Do Anesthesiologists Continue Improving After Residency? Figure 1. The performance trajectory for people learning new skills can follow various courses. Individuals generally develop adequate expertise in an everyday skill after a short training period, 50 hours or less. Actions become automatic at that point and performance plateaus. In contrast, people who pursue a competitive or highly technical professional activity continue to improve for a longer period, but performance will eventually arrest if training occurs in a rote manner. In contrast, individuals who follow an intensive training method called deliberate practice will improve for a longer, possibly indefinite period and reach an expert level of performance after 10 to 15 years of training. The deliberate practice strategy is unique in actively seeking improvement (see text). If the professional ceases deliberate practice, their improvement will cease and their performance will arrest at a lower level.10 Used with permission from Taylor & Francis Ltd, www.tandfonline.com.
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A relevant question is whether anesthesiologists routinely proceed to high-level performance after residency. Simulations involving anesthetic crises are appropriate models for testing high-level anesthesiology performance because managing critical incidents requires skills that numerous authorities associate with anesthesiology expertise.25–31 Henrichs et al.32 used quantitative assessment tools to evaluate how 35 practicing anesthesiologists (2–26 years in practice) performed with 8 scripted critical intraoperative events. In advance, the authors had suggested that accomplished anesthesiologists should perform at least 75% of the steps considered key for appropriate management. In fact,
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subjects accomplished 67% ± 12% of the key steps overall. Performance was approximately 60% for myocardial ischemia, blocked endotracheal tube, and total spinal scenarios and 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 PubMed searches were conducted on January 11, 2014, using the terms anesth* or anaesth* and “deliberate practice”; anesth* or anaesth* and “simulation.”
a
b
www.practicaldoc.ca.
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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.
Time Pressure
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 “OneMinute 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
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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
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E review article 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.
CONCLUSIONS
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.
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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.E DISCLOSURES
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. REFERENCES 1. Smith AF, Arfanis K. “Sixth sense” for patient safety. Br J Anaesth 2013;110:167–9 2. Gaba DM. Anaesthesiology as a model for patient safety in health care. BMJ 2000;320:785–8
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