Deliberate practice in medical education

The helicopter being brought out on the moving heli-pad, getting ready to head out on a job

I’ve been working with the helicopter crew here for the past few weeks and it’s really interesting to watch them learn, practice and train. Most of these guys are either pilots or trained in the military (or both) and its fascinating to watch as they proceed throughout their drills and exercises as well as actual rescues. They’re general approach can be summarized with the following:
1. Briefing: everyone gets together and they review what they’re going to do
2. Practice: they practice several times, progressively adding more realism and always in-situ (in this case within the helicopter)
3. Execute: do the job
4. Debrief: Everyone gets together, review what happened, did it go as planned?, any safety concerns? how can we do better?
Recently, I had my helicopter winch training and we very much followed this framework. The team met in the operations room, reviewed the plan where everyone had an opportunity to ask questions. We were doing a bunch of stuff that day including some stretcher winching with the paramedics so there was a considerable number of tasks that we were going to do within an hour. After the pilot took us through the whole plan, he then asked one of the crewman to recite the plan again (can’t say we ever do this in medicine…we often tell people what the plan is going to be, but rarely do we have a learner or team member then say it back again). After we headed out to the helicopter, the crewman walked me through the winching procedure. Then I did each step myself (in slow time) which was then followed by me going through it in real-time.
By the time we were in the air and I was ready to winch out, I had watched a demo and then done all the steps twice. Obviously this is a fairly high-stakes procedure where many things can go wrong so the value of this deliberate practice is high. Clearly something worked, since I made it back to write this blog post!!

HEMS team performing a winch procedure

In emergency medicine, we often don’t have the luxury of knowing or planning what the next trauma or medical resuscitation. However, for most procedures we do get to plan a little ahead of time. What if for the next intubation…the staff asks the senior resident to walk them through their plan and contingency plan (including cric)? What if this is done with everyone in the room as the preparations are being made?
Or maybe have the junior resident verbalize how they’ll do the LP then actually open the kit and show how they’ll do it?  And what about afterwards there’s a debrief, an opportunity to discuss any issues, successes or problems (obviously this isn’t always feasible) but I bet it could be better integrated.
One interesting concept for learning is the idea of “deliberate practice” which relates a bit to the above. Initially introduced by the psychologist Ericsson at Florida State University, it’s been described as “a highly structured activity explicitly directed at improvement of performance in a particular domain”. The authors of this article conducted a trial of deliberate practice among medical students and found there were positive effects including more planning behavior and increased tendency to structure their work.
They noted that there are four main design principles of deliberate practice (these mimic closely what we’re doing at the HEMS base):
  1. repetitive performance of cognitive or psychomotor skill
  2. rigorous skill assessment
  3. specific informative feedback
  4. better skills performance
In conclusion, the authors noted that deliberate practice helped students “learn how to learn” and use their time more efficiently.

2 thoughts on “Deliberate practice in medical education

  1. Great post Andrew!

    One of the most important lessons we as medical practitioners need to learn from the aviation industry is the importance of an effective debrief. In the ED setting its easy to take the short term view (the department is carnage tonight, so we’ll skip the debrief) instead of the long term view (we need to learn from our actions so that quality can improve and mistakes are not repeated). It occurred to me after reading your post that the most effective and educational debriefs I have attended have been in the context of SIMULATION, not the real thing…! Somehow I think this needs work…

    • exactly, probably the best debriefings I’ve been a part of also were following sim sessions. Rarely do we debrief an arrest or trauma. There’s huge opportunities for learning, not to mention the potential that some of the team members were affected emotionally and may benefit from discussion. Not sure how to incorporate this but must be a cultural shift.

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