Deliberate Practice

OVERVIEW

Deliberate practice involves repetitive performance of intended cognitive or psychomotor skills in a focused domain, coupled with rigorous skills assessment and feedback

  • deliberate implies that the technique requires the full attention and active, conscious actions by the learner
  • the feedback need not be from someone more expert at the task than the learner, just skilled observers who give effective feedback (e.g. elite sports coaches)
  • deliberate practice
    • allows specific skills to be maintained and developed over time
    • only develops the specific skill that is practised, it does not lead to ‘general’ skill development
  • given the short amount of time that can be spent with a coach/ teacher, solitary practice is the most important part of developing expertise
  • there are no shortcuts, there are no prodigies!

“The most effective method of all: deliberate practice. It is the gold standard, the ideal to which anyone learning a skill should aspire.” – Anders Ericsson

REQUIREMENTS FOR DELIBERATE PRACTICE

According to McGaghie et al (2010) Deliberate Practice requires the following elements:

  1. Highly motivated learners with good concentration who address
  2. well-defined learning objectives or tasks at
  3. an appropriate level of difficulty with
  4. focused, repetitive practice that yields
  5. rigorous, reliable measurements that provide
  6. informative feedback from educational sources (e.g., simulators, teachers) that 
promote
  7. monitoring, error correction, and more deliberate practice that enables
  8. evaluation and performance that may reach a mastery standard where learning time may vary but expected minimal outcomes are identical and allows
  9. advancement to the next task or unit

Ericsson emphasises that 2 other elements are required, which distinguish deliberate practice from purposeful practice:

  1. The field must be well established, and elite performers easily identified
    • there are ‘objective’ ways of measuring performance
    • usually competitive fields where there is a strong incentive to improve
    • the skills and the techniques for teaching them are highly developed and well understood (‘already figured out’)
  2. A coach or teacher guides training

ROLE OF THE COACH / TEACHER IN DELIBERATE PRACTICE

The Coach/ teacher

  • provides the ‘map’ that guides the learner towards the development of expertise
    • what to practice
    • what to focus on
    • Identifies that certain skills can only be taught and practised once others have been mastered
  • provides constant individualised feedback
    • identifies errors
    • identifies good performance
  • designs training activities (exercises and tasks) that target specific areas
    • individualises activities for the learner
    • activities correct bad habits and help refine or develop skills that the learner can take away and practice alone before the next coaching episode

The best coaches/ teachers

  • are accomplished in (1) their field and (2) instruction
  • can be identified by talking to their students who are at the same level as the prospective learner
    • beware of subjective judgements such as “fun”
    • focus on the progress that students make and the practice exercises that are provided

Learners may need to change teachers as their expertise increases

PURPOSEFUL PRACTICE

Purposeful practice is at the core of deliberate practice but can occur even if (1) the field is not established and true experts are not readily identifiable, and (2) a teacher/ coach is not available to guide training.

There are four principles of purposeful practice:

  1. Has a SMART goal(not a vague goal of ‘getting better’) and a plan for reaching the goal
  2. Involves maximal focus on improvement during practice: intense, uninterrupted and repetitive (‘drilling’)
  3. Provides immediate feedback on performance, which allows modification to achieve the goal
  4. Performed out of one’s comfort zone, trying to attempt something just out of one’s reach

“Any activity at the limit of your ability requires full concentration and effort” — Anders Ericsson

A general goal such as “get better” should be converted into a SMART goal that leads to step-by-step improvement by building on previously mastered skills to achieve a long term goal:

  • specific
  • measurable
  • achievable
  • relevant
  • time-specified

Deliberate practice is the ‘gold standard’ but is not always achievable.

  • Deliberate practice is purposeful practice ‘that knows exactly where it is going and how to get there’!

Purposeful practice is more accessible and can be achieved by these steps:

  1. identify experts
    • why are they considered experts?
    • what ‘objective’ measures identifies them as experts?
    • check criteria with peers (but note that people are swayed by many biases)
  2. figure out what makes them good/ sets them apart
    • ask them!
    • get them to ‘think aloud’ during performance
    • beware that they only have access to explicit factors, they may be unaware of aspects of their performance that are subconscious
  3. develop training techniques to develop the skills that have been identified

Remember the 3F’s

  • focus
  • feedback
  • fix it

IMPORTANCE OF MENTAL REPRESENTATIONS

Deliberate practice leads to the development, and reinforcement, of the learner’s ‘mental representations’ of the skill being practised.

  • expert performers, via their mental representations, are aware of how best to perform
  • provides “a view of the forest – that allows for rapid zoom to see the trees”
  • experts become ‘self-policing’, in that they modify their performance by comparing what they are doing in the moment with their mental representations of the skill
  • mental representations are the result of learning a skill but also help with developing the skill – a ‘virtuous circle’, “like climbing a staircase and building it at the same time”

The quality and quantity of mental representations sets expert performers apart from non-experts

  • ability to remember technical writing improves with increased subject knowledge
  • chest masters do not get better at remembering chest piece positions, only ‘encoded positions’ – patterns of the sort that can occur in a game

“In pretty much every area, a hallmark of expert performance is the ability to see patterns in a collection of things that would seem random or confusing to people with less developed mental representations. In other words, experts see the forest when everyone else sees only trees” – Anders Ericsson

MOTIVATION AND PERFORMANCE PLATEAUS

Performance plateaus

  • periods of stagnation rather than improvement during training
  • they are inevitable with all types of training
  • there is usually initial rapid uptake and improvement, that slows over time
  • can be overcome by identifying and specifically improving the perfromance components that are holding the learner back
    • what is holding the learner back?
    • what mistakes are occurring?
    • when do they occur?
    • if need to get faster then force performance in less amount of time and identify which component breaks down
    • may need to challenge the learner in a different way e.g. cross training

Motivation

  • Deliberate practice requires a highly motivated learner
  • Most people undergoing deliberate practice spend at least 1 hour per day practicing, usually in the morning
  • there is no scientific evidence for general”willpower”, motivation is always situation-specific
  • deliberate practice needs to be a habit and may require lifestyle redesign (similar to successful “weight losers”)
  • motivating factors may be internal and external

Strategies for remaining motivated to perform deliberate practice

  • focus on desire to improve
  • ensure adequate sleep, exercise and health to be able to maintain focus
  • start with shorter sessions with clear goals, then work up
  • stop when focus is lost
  • minimises anything that negatively influences training, e.g. distraction by smartphones
  • establish fixed times for practice with no other obligations or distractions
  • develop a sense of habit/ duty
  • develop a deliberate practice mindset — believe that talent is not innate and that you can succeed by training the right way
  • if an injury or setback has occurred, commit to only being able to quit once you have returned to your previous level (more likely to continue)
  • recognise observable progress and with rewards
  • utilise social motivation
    • surround self with like-minded others
    • provides a sense of identity, a support system and reinforcement by the approval of others
    • ensure that any training group has similar goals of improvement

LIMITATIONS OF DELIBERATE PRACTICE

  • true deliberate practice is not accessible to certain fields as the requirements cannot be met (e.g. political experts, psychotherapists, investors, wine experts)
  • some tasks (e.g. rarely performed medical procedures) are not easily repeatable (but may be simulated)
  • repetition of simulations is resource and time intensive
  • identification of key cognitive and psychomotor components that require repetition and analysis to improve the performance of complex tasks
  • requires high-level motivation as engaging in deliberate practice is almost universally considered unpleasant by learners (it is hard work, often boring, not fun!)
  • less effective with group sessions compared to one-on-one training
    • harder maintain focus and engagement
    • lacks continuous feedback
    • harder to individualise activities

RELEVANT RESEARCH

Ericsson, 2006

  • Deliberate practice is a more powerful predictor of superior expert performance than experience or academic aptitude

Maguire, 2011

  • subjects studying for the London taxi driver examination developed increases in the size of the posterior hippocampus
  • their improved performance was associated with decline in other tasks (deliberate practice is specific)
  • in subjects who stopped training the posterior hippocampus decreased in size again and performance declined

? reference ? reference

  • performance of concert violinist trainees correlates with number of hours of solitary practice
  • the major differences between concert violinist trainees is the amount of solitary practice in the preteen and teen years

THE GIFT FALLACY

The gift fallacy is the belief that highly talented individuals are born, not made

  • Anders Ericsson states in Peak that in over 30 years of studying a very wide range of expert performers (e.g. chess grandmasters, Nobel prize winners, concert violinists, elite sports professionals) he is yet to discover a genuine ‘prodigy’.
  • Ericsson even explains that Mozart’s prodigious ability was a result of deliberate practice guided by a highly skilled teacher (his father, a noted composer) from a very young age. Ericsson also states that numerous children today, thanks to more modern training techniques and other advantages, have superseded his age-matched techinical ability

Exceptions:

  • these occur, to some extent, where talent is dependent on biologically-determined characteristics such as height and body size (e.g. basketball)
  • it is possible that individuals vary in their predispositions to engaging in deliberate practice, however, it seems that all healthy people have the ability to adapt and improve if trained correctly

“Talent does not exist… I am not talented, I am obsessed” – Conor McGregor, UFC lightweight champion

NAIVE PRACTICE AND THE MYTH OF THE ‘10,000 HOURS RULE’

Naive practice

  • unfocused experience engaged in an activity
  • simply stockpiling experience does not lead to expertise
  • trying hard alone does not lead to progress, practice must be performed the right way

“doing the same thing the same way… is a recipe for stagnation and gradual decline” — Anders Ericsson and Robert Pool

‘10,000 hours rule’

  • popularised by Malcolm Gladwell in his book Outliers, based on Ericsson’s work on training concert violinists
  • Gladwell based his ‘rule’ on Ericcson’s finding that the elite violinists out of the trainee group had all spent an average of 10, 000 hours by the age of 20 in solitary practice, as compared to the less skilled (but still very good!) trainees who had a few less thousand hours on the clock. However, the few that went on to win international music competitions did so at 30+, when they had put in over 20,000 hours of practice
  • Limitations of the ‘10,000 hour rule’
    • To reach a certain level of expertise will require differing durations of practice, depending on the individual and the area of expertise
    • For the violinists, the 10,000 hours was just an average
    • The time required by violinists would depend on the level of competition
    • time does not guaranteee expertise, it must involve deliberate practice (not naive practice)
  • The kernel of truth in the ‘10,00 hours rule’ is that expertise does require a very long time engaged in deliberate practice to develop, but the duration is not fixed

RELEVANCE TO MEDICINE

The traditional focus of medical education has been on knowledge rather than skills (easier to teach and test!)

  • Davis et al (1999) showed that the interactive components of medical CME are the most effective (e.g. role pay, discussion groups, case solving and hands on training) and that lectures were relatively ineffective
  • Forsetlund (???) found that:
    • no type of medical CME is effective at improving complex behaviours
    • CME currently has a small effect on doctor performance and an even smaller effect on patient outcomes

Possible approaches in medicine

  • Use highly skilled proceduralists to coach less technically skilled colleagues
  • use of case/ imaging databases with known outcomes

CONCLUSION

  • In certain fields, true expertise can be developed through deliberate practice
  • Skill is not dependent on natural talent, and cannot be developed through time and effort alone (e.g. naive practice for 10,000 hours!)
  • In some fields the requirements for deliberate practice cannot be explicitly met (e.g. in medicine it may be hard to accurately identify elite performers). However, significant performance improvement is still possible by approximating deliberate practice as close as possible

References and Links

Journal articles and books

  • Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic medicine. 79(10 Suppl):S70-81. 2004. [pubmed]
  • Ericsson KA. 2006. The Influence of Experience and Deliberate Practice on the Development of Superior Expert Performance. In: Ericsson KA, Charness N, Feltovich PJ, Hoffman RR. The Cambridge Handbook of Expertise and Expert Performance. Cambridge. Cambridge University Press; 2006. [book]
  • Hastings RH, Rickard TC. Deliberate practice for achieving and maintaining expertise in anesthesiology. Anesthesia and analgesia. 120(2):449-59. 2015. [pubmed]
  • McGaghie WC. Research opportunities in simulation-based medical education using deliberate practice. Academic emergency medicine. 15(11):995-1001. 2008. [pubmed]
  • McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research: 2003-2009. Medical education. 44(1):50-63. 2010. [pubmed]
  • Ross PE. The Expert Mind. Sci Am. 295(2):64-71. 2006. [article]

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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

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