Deliberate Practice in Emergency Medicine

What defines expertise in emergency medicine? With a broad approach towards acute presentations in all specialties it’s difficult to define what makes an exceptional EM doctor. There are notions that we should be expert diagnosticians who are quick to call out non-emergent complaints or malingerers, in control of the flow of patients and ready to stop what we’re doing to run a resuscitation at any moment. Doing this requires refinement of a number of discrete skills through deliberate practice.

This post is a look at applying deliberate practice to emergency medicine using concepts outlined by Anders Ericsson, a psychologist who spent his life’s work demystifying how expertise is obtained. To understand deliberate practice it’s important to address two commonly held misconceptions about expertise:

Innate talent

There are no expert performers in any craft who did not spend an exorbitant amount of time perfecting their skills, and if one closely examines the history of expert performers at a young age they will find a proportionally young start to their deliberate practice. In his book “Peak,” Ericsson stated that he has yet to discover a genuine prodigy through studying a wide variety of expert performers from concert violinists to elite sports professionals.

10,000 hour rule taken out of context

One of Professor Ericsson’s most famous studies was an evaluation of what separated high level violinists at the Academy of Music in Berlin. The study divided music students into three groups, those who could be world-class performers, those who were very good, and those who were less skilled but could find work as music teachers. He found that what separated violinists’ skills was the number of hours of practice logged since childhood. The future teachers registered around 4,000 hours, the very good 8,000, and the elite performers more than 10,000. The study was replicated with pianists and now the 10,000 hour concept is widely known.

10,000 hours of thoughtless activity adds nothing to one’s performance. The hours used need to be focused on growth with expectations, assessments of performance, and varied practice. One can drive to work hours on end, but it doesn’t make them an expert driver. Only perfect practice makes perfect.

Deliberate Practice at Methodist

Three years of EM residency at Methodist gives you approximately 5,000 hours of practice in a busy Brooklyn emergency department with a roughly equal number of patient encounters. Are residents halfway to expertise after graduation? Our field is too broad, and there may even be situations where growth slows after residency in complacency without the parameters of a training program to encourage improvements.

Regardless of our own goals, there are parameters built into hospital systems where we are likely to get recurrent systematic feedback that inevitably guide our practice:

● Stroke time to TPA

● Sepsis protocol adherence

● STEMI door to balloon time

● Patient satisfaction scores

● What does the “to be seen” list look like to colleagues coming on, how’s flow?

● How are we going to look if this case goes to court, M&M, or bounces back?

In addition to the systematic parameters we may or may not want guiding our practice, here are some areas that we can autonomously work towards:

● Resuscitations

● Difficult Airway Management

● EKG interpretation

● Documentation and Communication

● Clinical Acumen

● Ultrasound

● Teaching Acumen

Such parameters, whether set by us or the institution we work in, will in turn guide our future practice. Now, with this overview of what we could specifically develop expertise in, how can we use deliberate practice to get there?

Concept of mental representations

Expertise in chess is directly correlated to the number of potential moves one can consider to guide them towards the best possible move. Similarly in our field, our ability to manage whatever comes through the door depends on how many different cases and approaches we are ready to consider based on our previous practice. The more mental representations of possible diagnoses, drug choices, procedural approaches, and interactions between variables gives us a stronger grasp of medicine and a wider range of practice.

How can we build upon our repertoire of possible clinical scenarios and treatment options?

● Spaced repetition to memorize core content, medications, etc

● Simulation and regular brush up practice for rare cases/procedures like cricothyrotomies

● Sharing notable EKGs and interesting presentations

● Keeping up to date on the latest literature

● Taking new approaches and challenging ourselves in routine practice

● Seeking feedback whether from consultants, colleagues, or mentors

● Debriefs after notable cases

● Involvement in quality assurance

A few tips to help you stay sharp to take part in purposeful/deliberate practice:

Examples include attempting new approaches to intubations, ultrasound guided procedures, approaches to running long distances, learning a new language.

● You should be well rested when pushing yourself

● Be patient, try new/difficult things for 15-20 minutes at a stretch at first.

● Need a coach or mentor to guide practice and provide quality feedback to improve most efficiently. Part of developing expertise is the ability to clearly see how we are doing and bridge the gap in our practice.

● Focus, Feedback, Fix. 3 F’s

• Be aware of what you’re doing when you’re practicing deliberately.

• Get feedback either from patient reports, vitals, self-made parameters, mentors/peers.

• Fix what you need to perform at a higher level.

Through roughly 5000 hours of practice in residency and further growth as attendings we can continually refine our skills as EM physicians. Our practice will change over time as we are influenced to work towards specific hospital systems or department based parameters. Through deliberate practice we can guide our practice towards developing skills we value, and continue to learn by pushing the limits of what we are capable of accomplishing over the thousands of hours and patient encounters that make up our career.

References:

Ericsson, K Anders Deliberate Practice and the Acquisition and Maintenance of Expert Performance in Medicine and Related Domains, Academic Medicine: October 2004 - Volume 79 - Issue 10 - p S70-S81

Weingart, Scott. “EMCrit Podcast 212 - Thoughts on Deliberate Practice and Expertise.” EMCrit Project, 7 Apr. 2021, emcrit.org/emcrit/thoughts-on-deliberate-practice-expertise/.

Kurutz, Steven. “Anders Ericsson, Psychologist and 'Expert on Experts,' Dies at 72.” The New York Times, The New York Times, 1 July 2020, www.nytimes.com/2020/07/01/science/anders-ericsson-dead.html.