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Deliberate Practice and the Acquisition and Maintenance of Expert Performance in Medicine and Related Domains
Abstract
The factors that cause large individual differences in professional achievement are only partially understood. Nobody becomes an outstanding professional without experience, but extensive experi- ence does not invariably lead people to become experts. When individuals are first introduced to a professional domain after com- pleting their education, they are often overwhelmed and rely on help from others to accomplish their responsibilities. After months or years of experience, they attain an acceptable level of proficiency and are able to work independently. Although everyone in a given domain tends to improve with experience initially, some develop faster than others and continue to improve during ensuing years. These individuals are eventually recognized as experts and masters. In contrast, most professionals reach a stable, average level of performance within a relatively short time frame and maintain this mediocre status for the rest of their careers. The nature of the individual differences that cause the large variability in attained performance is still debated. The most common explanation is that achievement in a given domain is limited by innate factors that cannot be changed through experience and training; hence, limits of attainable performance are determined by one's basic endow- ments, such as abilities, mental capacities, and innate talents. Educators with this widely held view of professional development have focused on identifying and selecting students who possess the necessary innate talents that would allow them to reach expert levels with adequate experience. Therefore, the best schools and professional organizations nearly always rely on extensive testing and interviews to find the most talented applicants. This general view also explains age-related declines in professional achievement in terms of the inevitable reductions in general abilities and capac- ities believed to result from aging. In this article, I propose an alternative framework to account for individual differences in attained professional development, as well as many aspects of age-related decline. This framework is based on the assumption that acquisition of expert performance requires engagement in deliberate practice and that continued deliberate practice is necessary for maintenance of many types of professional performance. In order to contrast this alternative framework with the traditional view, I first describe the account based on innate talent. I then provide a brief review of the evidence on deliberate practice in the acquisition of expert performance in several performance domains, including music, chess, and sports. Finally, I review evidence from the acquisition and maintenance of expert performance in medicine and examine the role of deliberate practice in this domain.
... Visual expertise in ECG interpretation is more than a matter of accumulating knowledge; it involves the development of refined cognitive strategies that allow clinicians to focus on diagnostically relevant elements of the ECG while minimizing distractions (Ericsson 2004;Rosen et al. 2018;Wathen et al. 2019). Expert interpreters, through years of clinical practice, appear to develop an intuitive ability to recognize critical patterns, a skill that allows them to quickly identify abnormalities even in the presence of complex or atypical presentations (Qiao et al. 2018;Wood et al. 2016). ...
... The primary data comprised eye-tracking metrics-fixation count, fixation duration, and pupil dilation-analyzed using the advanced Tobii Pro Lab software. Fixation count provided a quantitative measure of the number of visual engagements with distinct regions of the ECG, offering insight into the breadth of the search strategy (Ericsson 2004;Rosen et al. 2018;Wathen et al. 2019). Fixation duration captured the depth of focus, revealing the time spent analyzing critical segments of the ECG waveform (Qiao et al. 2018;Wood et al. 2016). ...
... Color intensity reflects pupil dilation, with warmer tones (yellow/red) indicating higher cognitive load (greater dilation) and cooler tones (blue/green) representing lower load (less dilation a matter of speed but reflect a deeper cognitive economy. By quantifying how much cognitive effort each participant exerted, this study sheds light on the cognitive strategies that underpin expert performance, offering a more holistic perspective on the evolution of visual expertise (Ericsson 2004;Rosen et al. 2018;Wathen et al. 2019). ...
Background
Visual expertise is pivotal for accurate ECG interpretation. We aimed to identify and measure expertise‐based differences in visual search patterns, cognitive load, and diagnostic accuracy during ECG analysis using eye‐tracking technology.
Methods
First‐ to third‐year residents and board‐certified expert cardiologists interpreted ECGs of patients with suspected acute coronary syndrome, while eye‐tracking glasses recorded fixation count, duration, and pupil dilation. Diagnostic accuracy and cognitive load via NASA Task Load Index were analyzed. Heatmaps illustrated relationships between cognitive load, perceived workload, and self‐assessed performance across experience levels and ECG task complexities.
Results
Expert readers interpreted ECGs significantly faster than residents (107.6 ± 32.8 vs. 205.31 ± 57.43 s; p < 0.001) and demonstrated higher diagnostic accuracy across all levels of task difficulty (p < 0.001). Eye‐tracking analysis revealed that experts exhibited fewer fixations (67.7 ± 25.7 vs. 143.7 ± 29.9; p < 0.001) and longer fixation durations (3.9 ± 0.7 vs. 3.2 ± 1 s; p = 0.032) than residents. Experts also showed lower pupil dilation changes (4.8% ± 2% vs. 10.5% ± 4.2%; p = 0.015). Increased task difficulty was associated with greater pupil dilation, particularly among novices (mean pupil dilation for difficult tasks 13.4% ± 4.1% vs. 7.3% ± 2.3% for easy tasks; p = 0.008), indicating higher cognitive demand. Experts maintained superior self‐assessed performance (8 ± 0 vs. 7 ± 1.2; p = 0.009) and reported lower perceived negative workload (4.5 ± 1.45 vs. 6 ± 0.55; p = 0.041).
Conclusions
In this pilot study, expert readers achieved faster and more accurate diagnoses, exhibiting more efficient visual search patterns and lower cognitive load. Pending external validation, our findings suggest that ECG training programs should focus on developing targeted visual techniques, cognitive efficiency, and adaptive coping strategies to enhance accurate interpretation.
... These learning goals are based on internationally recognized frameworks, such as the Consensus Statement on the Content of Clinical Reasoning Curricula in Undergraduate Medical Education, which emphasizes hypothesis-driven history-taking, generating prioritized differential diagnoses, and structured reflection to iteratively refine diagnostic accuracy [4]. Achieving these learning goals is essential for fostering diagnostic accuracy, effective clinical reasoning, and patient-centered decision-making, which are critical competencies for medical students to develop to become safe and competent clinicians [3][4][5][9][10][11]. Clinical reasoning encompasses generating a hypothesis, developing a differential diagnosis from the patient's chief complaint, and continuously refining these based on new information gathered through targeted history-taking, physical examinations, and investigations [3][4][5][9][10][11][12]. ...
... These learning goals are based on internationally recognized frameworks, such as the Consensus Statement on the Content of Clinical Reasoning Curricula in Undergraduate Medical Education, which emphasizes hypothesis-driven history-taking, generating prioritized differential diagnoses, and structured reflection to iteratively refine diagnostic accuracy [4]. Achieving these learning goals is essential for fostering diagnostic accuracy, effective clinical reasoning, and patient-centered decision-making, which are critical competencies for medical students to develop to become safe and competent clinicians [3][4][5][9][10][11]. Clinical reasoning encompasses generating a hypothesis, developing a differential diagnosis from the patient's chief complaint, and continuously refining these based on new information gathered through targeted history-taking, physical examinations, and investigations [3][4][5][9][10][11][12]. Essential skills include recalling appropriate diagnostic steps, organizing clinical information effectively, and identifying key clues for diagnosis [3][4][5][9][10][11][12]. ...
... Achieving these learning goals is essential for fostering diagnostic accuracy, effective clinical reasoning, and patient-centered decision-making, which are critical competencies for medical students to develop to become safe and competent clinicians [3][4][5][9][10][11]. Clinical reasoning encompasses generating a hypothesis, developing a differential diagnosis from the patient's chief complaint, and continuously refining these based on new information gathered through targeted history-taking, physical examinations, and investigations [3][4][5][9][10][11][12]. Essential skills include recalling appropriate diagnostic steps, organizing clinical information effectively, and identifying key clues for diagnosis [3][4][5][9][10][11][12]. Additionally, reflecting on one's errors and integrating patient-centered insights further strengthen the clinical reasoning process [4,11]. ...
Background
Clinical reasoning skills are essential competencies for medical students; therefore, effective, evidence-informed teaching methodologies are needed worldwide. This study investigated the benefits of team-based learning (TBL) for developing the skills in medical students.
Method
A mixed-methods sequential explanatory design was used to investigate the effectiveness of TBL for medical students acquiring clinical reasoning skills. The study participants comprised 92 fourth-year medical students at Yokohama City University School of Medicine, participating in TBL sessions that covered 10 major clinical symptoms identified in the core curriculum. Each session lasted 240 min. Before and after the educational intervention, student performance was measured using the script concordance test (SCT) on a 30-point scale, and self-assessed clinical reasoning competency was measured on a 7-point Likert scale. The SCT included pre-tests and post-tests of 30 questions each, with students randomly assigned to one of two test sets. Following the quantitative evaluation, a qualitative content analysis was conducted to explore the advantages of TBL for learning clinical reasoning skills. The analytic categories were set according to the six levels of Fink’s taxonomy of significant learning.
Result
Student performance improved significantly after the educational intervention (A test: 16.5 ± 4.4 to 18.7 ± 4.5, p = 0.019; B test: 18.1 ± 3.7 to 19.8 ± 4.4, p = 0.028). After the educational intervention, self-assessed clinical reasoning competency was significantly higher in “recalling appropriate physical examination and tests on clinical hypothesis generation,” “recalling appropriate differential diagnosis from patient’s chief complaint,” “verbalizing points that fit/don’t fit the recalled differential diagnosis appropriately,” “verbalizing and reflecting appropriately on own mistakes,” “selecting keywords from the whole aspect of the patient,” and “practicing the appropriate clinical reasoning process” (all p < 0.001). The content analysis extracted 23 subcategories and 233 codes of the advantages of TBL for learning clinical reasoning skills, covering all six levels of Fink’s taxonomy of significant learning: Foundational knowledge (7 codes); Application (40 codes); Integration (69 codes); Human dimension (89 codes); Caring (8 codes); and Learning how to learn (20 codes).
Conclusion
This study demonstrates that TBL supports the acquisition of critical clinical reasoning skills among medical students.
... Our findings align with existing literature that emphasizes the importance of deliberate practice and continuous feedback in surgical education. Ericsson's theory of deliberate practice highlights the necessity of focused, repetitive practice with continuous feedback to achieve expert performance [13]. Similarly, Stefanidis and colleagues have shown that proficiency-based laparoscopic simulator training, which involves repeated practice until a specific level of competence is achieved, leads to better skill retention and transferability [14]. ...
... They suggested smaller group sizes to enhance individual attention and learning, provision of preparatory materials before the workshop, and inclusion of additional skills such as suturing and information about surgical instrumentation. These suggestions align with existing literature, which emphasizes the importance of tailored, repetitive training, and comprehensive skill coverage in surgical education [13,14]. Smaller group sizes can facilitate more personalized instruction and immediate feedback, which are crucial for effective learning. ...
... To address the limitations identified and further enhance the workshop's effectiveness, several strategies can be implemented. Research on deliberate practice and proficiency-based training suggests that incorporating multiple training sessions could lead to better skill retention and transferability [13,14]. In addition, expanding the workshop to cover a broader range of surgical procedures and scenarios, as recommended by participants, could better prepare students for the diverse situations they will encounter in the OR. ...
Operating room (OR) sterility and proficiency are paramount in medical education, yet a standardized curriculum remains elusive. This study investigates the impact of an OR skills training workshop, led by students and supervised by OR staff, on third-year medical students' confidence and comfort in the OR setting. Third-year students at Quillen College of Medicine in Johnson City, Tennessee, participated in pre- and post-workshop surveys assessing comfort levels with key OR procedures. The workshop facilitated practice in a low-pressure environment, enhancing students' confidence significantly across six fundamental OR skills (p < 0.05). Strengths of the workshop included facility tours, hands-on practice, and mentorship by OR staff, while recommendations focused on smaller group sizes and additional skill coverage. Ongoing data collection aims to assess the workshop's long-term impact on clerkship experiences. This study underscores the importance of structured curriculum enhancements in surgical medical education.
... "Resource" characteristics related to skills, intelligence, experiences or material resources play a role. For example, research shows the importance of learners using evidence-based studying and test preparation strategies for deep learning, [6][7][8][9][10][11] but students need to learn and use these strategies. "Force" characteristics, such as factors related to temperament and personality, may all have an impact on a person's development. ...
... We analyzed data from answers to PMQ questions that asked examinees how they created their study plans, studied for the test, practiced with questions that mimic MCAT questions, and practiced for the test day itself (i.e., evidence-based learning and studying strategies, List 1). [6][7][8][9][10][11] These questions were added to the PMQ in 2019 to better understand potential differences in how students prepare for the MCAT exam, as well as challenges potentially experienced by students from lower-SES and other disadvantaged backgrounds. 20,21 We also analyzed PMQ data about the use of the top five "high-value" free and low-cost MCAT preparation resources, which were selected for analysis based on reports of usage and usefulness: the official AAMC MCAT Practice Exams, MCAT Sample Test, MCAT Question Packs, MCAT Section Bank, and Khan Academy MCAT Collection. ...
Phenomenon: On the Medical College Admission Test (MCAT), required for entry into all medical schools in the U.S. and many in Canada, average scores are typically lower for individuals from lower socioeconomic status (SES) backgrounds compared to their more advantaged peers, although individuals from every background score in the lower, middle, and upper ranges of the score scale. This achievement gap is potentially due in part to disparities in resource utilization and effective study strategies. Viewing this challenge through a socioecological systems lens can help identify potential systems-level opportunities to support students from these backgrounds to succeed in medicine. Approach: This investigation was the first large-scale review of MCAT preparation strategies, resource utilization, and challenges for examinees from lower-SES backgrounds, focusing on those who obtained higher versus lower MCAT scores. It aimed to examine differences in students' use of evidence-supported learning/studying strategies and challenges experienced in preparing for the MCAT exam. Survey data from the Association of American Medical Colleges Post-MCAT Questionnaire on MCAT preparation strategies and resources used and challenges experienced by 2021-2023 examinees were analyzed, focusing on the 3,240 survey respondents from lower-SES backgrounds. T-tests and chi-square analyses compared continuous variables and proportions between lower- and higher-scoring examinees from lower-SES backgrounds, using Cohen's h to estimate effect size. Findings: Higher-scoring examinees reported greater use of many evidence-supported effective test preparation and learning strategies, including discussing preparation strategies with advisors/peers, establishing baseline capabilities, practicing applying knowledge to practice questions, and evaluating readiness by taking a practice test. Utilization rates of high-value, free/low-cost MCAT resources were significantly higher among top scorers. Conversely, lower-scoring examinees were more likely to report challenges in obtaining reliable internet access, determining how to begin studying, and accessing concrete information about the MCAT exam. Insights: This study highlights critical differences in preparation approaches and challenges among examinees from lower-SES backgrounds. Identifying these gaps may provide insights regarding interventions to improve access to resources and potential improvement to MCAT performance. We provide systems-level ideas for how to better support students from lower-SES backgrounds. For example, learning specialists and advisors could use the findings from this study to screen and educate examinees about evidence-based MCAT preparation strategies and resources. This study identifies opportunities to inform interventions to help students from lower-SES backgrounds advance toward a career in medicine.
... However, positive perceptions do not necessarily equate to better practical performance, highlighting the importance of deliberate practice alongside an effective learning environment (Ericsson K. Anders, 2004). ...
... However, a notable finding is the absence of a direct correlation between positive perceptions and practical competence, underscoring the need for improvements in content and teaching methods to better support skill development (Ericsson K. Anders, 2004). ...
This study was conducted at Can Tho University of Medicine and Pharmacy, a leading health sciences institution in the Mekong Delta region, to evaluate the adequacy of the medical skills training program for fifth-and sixth-year medical students. This study utilizes a quantitative methodology, gathering data from survey questionnaires completed by fifth-and sixth-year medical students at Can Tho University of Medicine and Pharmacy. The research aims to evaluate students' proficiency in medical skills practice and to investigate how variables such as academic year, academic performance, and post-graduation career preferences influence students' perceptions of the medical skills training program. A quantitative study involving 462 fifth-and sixth-year medical students demonstrated a high level of responsiveness to the medical skills training program (p < 0.001). However, no statistically significant correlation was observed between students' perceptions of the program and their competency in medical skills practice. This study reveals that a positive perception of the medical skills training program does not directly translate into superior practical competency. Academic performance emerged as a key determinant, with students in the 'Good-Excellent' category demonstrating a significantly higher responsiveness rate (90.3%) than their 'Average-Poor' counterparts (77.9%) (p < 0.001). Furthermore, students' intended post-graduation workplace influenced their perception, with those planning to work at the provincial level reporting a more favorable evaluation than those targeting district-level positions. However, no significant differences in practical competency were observed between these groups. These findings highlight the critical need for curriculum enhancements, improved infrastructure, and increased engagement of clinical faculty to ensure the effectiveness of medical skills training programs. Resumo. Este estudo foi conduzido na Can Tho University of Medicine and Pharmacy, uma instituição líder em ciências da saúde na região do Delta do Mekong, para avaliar a adequação do programa de treinamento de habilidades médicas para estudantes de medicina do quinto e sexto ano. Este estudo utiliza uma metodologia quantitativa, coletando dados de questionários de pesquisa preenchidos por estudantes de medicina do quinto e sexto ano na Can Tho University of Medicine and Pharmacy. A pesquisa visa avaliar a proficiência dos alunos na prática de habilidades médicas e investigar como variáveis como ano acadêmico, desempenho acadêmico e preferências de carreira pós-graduação influenciam as percepções dos alunos sobre o programa de treinamento de habilidades médicas. Um estudo quantitativo envolvendo 462 estudantes de medicina do quinto e sexto ano demonstrou um alto nível de responsividade ao programa de treinamento de habilidades médicas (p < 0,001). No entanto, nenhuma correlação estatisticamente significativa foi observada entre as percepções dos alunos sobre o programa e sua competência na prática de habilidades médicas. Este estudo revela que uma percepção positiva do programa de treinamento de habilidades médicas não se traduz diretamente em competência prática superior. O desempenho acadêmico surgiu como um determinante-chave, com os alunos na categoria 'Bom-Excelente' demonstrando uma taxa de responsividade significativamente maior (90,3%) do que seus colegas 'Médio-Ruim' (77,9%) (p < 0,001). Além disso, o local de trabalho pretendido pelos alunos após a graduação influenciou sua percepção, com aqueles que planejam trabalhar no nível provincial relatando uma avaliação mais favorável do
... Typically, these cognitive capabilities are developed through deliberate practice and hands-on experience in reading, analyzing, and synthesizing information [4]. As GenAI makes it possible to automate many aspects of document processing and analysis, we must carefully consider how to preserve and augment opportunities for expert judgment and synthesis. ...
... Second, for novices or practitioners developing expertise, the framework of deliberate practice suggests that expertise development requires sustained engagement with increasingly challenging tasks, coupled with immediate feedback and opportunities for reflection [4]. This raises concerns about how automation might limit these crucial learning processes. ...
As Generative AI (GenAI) capabilities expand, understanding how to preserve and develop human expertise while leveraging AI's benefits becomes increasingly critical. Through empirical studies in two contexts -- survey article authoring in scholarly research and business document sensemaking -- we examine how domain expertise shapes patterns of AI delegation and information processing among knowledge workers. Our findings reveal that while experts welcome AI assistance with repetitive information foraging tasks, they prefer to retain control over complex synthesis and interpretation activities that require nuanced domain understanding. We identify implications for designing GenAI systems that support expert cognition. These include enabling selective delegation aligned with expertise levels, preserving expert agency over critical analytical tasks, considering varying levels of domain expertise in system design, and supporting verification mechanisms that help users calibrate their reliance while deepening expertise. We discuss the inherent tension between reducing cognitive load through automation and maintaining the deliberate practice necessary for expertise development. Lastly, we suggest approaches for designing systems that provide metacognitive support, moving beyond simple task automation toward actively supporting expertise development. This work contributes to our understanding of how to design AI systems that augment rather than diminish human expertise in document-centric workflows.
... However, positive perceptions do not necessarily equate to better practical performance, highlighting the importance of deliberate practice alongside an effective learning environment (Ericsson K. Anders, 2004). ...
... However, a notable finding is the absence of a direct correlation between positive perceptions and practical competence, underscoring the need for improvements in content and teaching methods to better support skill development (Ericsson K. Anders, 2004). ...
This study was conducted at Can Tho University of Medicine and Pharmacy, a leading health sciences institution in the Mekong Delta region, to evaluate the adequacy of the medical skills training program for fifth- and sixth-year medical students. This study utilizes a quantitative methodology, gathering data from survey questionnaires completed by fifth- and sixth-year medical students at Can Tho University of Medicine and Pharmacy. The research aims to evaluate students' proficiency in medical skills practice and to investigate how variables such as academic year, academic performance, and post-graduation career preferences influence students' perceptions of the medical skills training program. A quantitative study involving 462 fifth- and sixth-year medical students demonstrated a high level of responsiveness to the medical skills training program (p < 0.001). However, no statistically significant correlation was observed between students' perceptions of the program and their competency in medical skills practice. This study reveals that a positive perception of the medical skills training program does not directly translate into superior practical competency. Academic performance emerged as a key determinant, with students in the 'Good-Excellent' category demonstrating a significantly higher responsiveness rate (90.3%) than their 'Average-Poor' counterparts (77.9%) (p < 0.001). Furthermore, students' intended post-graduation workplace influenced their perception, with those planning to work at the provincial level reporting a more favorable evaluation than those targeting district-level positions. However, no significant differences in practical competency were observed between these groups. These findings highlight the critical need for curriculum enhancements, improved infrastructure, and increased engagement of clinical faculty to ensure the effectiveness of medical skills training programs.
... Active methods involve taking part in discussions, practicing on procedural simulators and teaching. However, these "simple experience" methods are generally not sufficient to achieve Level 5, unlike deliberate practice [6]. This pedagogical approach involves setting objectives based on feedback provided by an external observer, ideally a Level 5 expert. ...
... In our study, we observed a strong improvement in objective performance in the deliberate practice group compared with the naive practice group when learning to place fibula plates. This difference can be explained by the expert's personalized advice based on each learner's errors [6]. These results concur with those of Ericsson, who emphasized that mere repetition is not enough to improve performance [3]. ...
Introduction
Historically, surgical training has been primarily carried out in the operating theatre, using mentoring for the surgical resident to reach the appropriate skill level (3/5). Other surgical training methods also improve performance, but do not always lead to the highest level of expertise (5/5). Another training method, sometimes termed- deliberate practice, by setting objectives based on feedback, may be more effective.
In this study we compared resident learning of osteosynthesis for a fibular fracture model between deliberate practice and traditional teaching or naive practice. The main hypothesis was that deliberate practice would result in better objective performance, better subjective performance and reduced stress levels.
Materials and methods
The study involved a level 3 expert and ten level 1 surgeon-in-training subjects divided into two groups naive practice and deliberate practice. Each subject placed 5 plates on a synthetic fibula model. The deliberate practice group received feedback from the expert after each trial. Stress level was measured using the Analgesia Nociception Index (ANI). Objective performance was assessed by OSATS and subjective performance by self-assessment.
Results
Based on initial performance measurements, the two groups were comparable. The mean progression of objective performance over the five osteosynthesis was 10.3 in the naive practice group and 17.1 in the deliberate practice group, with a strong difference in favor of the deliberate practice group. Subjective performance and ANI improved in both groups, with no significant difference.
Discussion
The main hypothesis was disproven: the improvement in objective performance was not significantly greater (< 97.5%) with deliberate practice. However, there was a substantial difference in favor of the deliberate practice group (93%). Secondary hypotheses were not proven too, as neither PS nor ANI were affected by deliberate practice. In conclusion, deliberate practice complements mentoring but must adhere to strict guidelines to be effective: level 5 expertise, precise criteria for defining OSATS, and the use of high- profile simulators.
... 9,11,12 Helping to develop these higher-level skills is the goal of many educational approaches, as being able to monitor and continuously improve one's performance is a feature of expert performance. 13 For example, self-assessment can encourage learners to reflect on and improve their own performances. 14,15 However, some learners over-or under-estimate their own performances 14 . ...
... 30 The protocol that participants followed in the current study included some elements of deliberate practice, including opportunities for learners to practice based on feedback. 13 Learners reflected on information/feedback about a demonstrator's performance, in the hopes that they could apply it to their own performance of the task. Studies exploring how to optimize improvements in medical/surgical skill performance through observation have found mixed results regarding whether or not learners should receive information about the quality of the demonstrator's performance, and the type of demonstrator that should be observed. ...
... [8][9][10] Clinical skills are learned by deliberate practice, which consists of repetitive practice of a specific skill with targeted feedback from instructors; models facilitate deliberate practice in a way that is difficult to achieve using only live animals requiring the procedure. 11,12 Models also support the principles of the 3Rs (Replacement, Reduction, and Refinement) of animal use 13 and comply with the AAVMC's animal use guidelines, which recommend initially teaching students to perform clinical skills using models instead of live animals. 14 Large animal clinical skills models are less common and less well researched than small animal models. ...
... Models are widely used in teaching veterinary clinical skills 8,10,31,32 because they facilitate deliberate practice, 11,33 improve students' competence, 31 reduce students' stress in performing procedures on the live animal, 34 and shorten students' procedural times. 35 Historically, models simulating procedures in large animals, and particularly in food animals, have been underrepresented in the veterinary simulation literature. ...
Bovine uterine prolapse is a common but emergent condition typically arising in the time surrounding calving. Without treatment, it can result in tissue trauma, infection, hemorrhage, and death. Teaching veterinary students to perform uterine prolapse reduction has historically been dependent upon adequate clinical caseload requiring the procedure. This study sought to develop and collect validation evidence for a silicone bovine uterine prolapse reduction model and associated scoring rubric to enable procedural practice without the presentation of live animals requiring the procedure. This study utilized a validation framework consisting of content evidence (expert opinion), internal structure evidence (reliability of scores produced by the rubric), and relationship with other variables evidence (level of training, novice-to-expert comparison). Veterinary students ( n = 37, novices) and veterinarians ( n = 11, experts) performed the procedure on the model while being video recorded. All participants then completed a survey about the model. Veterinarians’ survey results indicated that the model adequately represented the task and was suitable for teaching and assessing veterinary students’ skill in the procedure (content evidence). Scores produced by the rubric had a marginal Cronbach's alpha (.607), suggesting that the rubric may be adequate for low-stakes assessment but would require additional items or modification in order to improve reliability and be suitable for high-stakes assessment (internal structure evidence). Finally, experts achieved higher total rubric scores than novices did (relationship with other variables evidence). This study demonstrated content evidence and relationship with other variables evidence for the bovine uterine prolapse model, indicating its usefulness for teaching this important clinical skill.
... El Marco de Competencias Globales del TDR según lo menciona Ericsson (2024), para la Investigación Clínica finalizado consta principalmente de una Rueda de Competencias, que es aplicable a todos los roles de investigación. Presenta visualmente el marco con sus 50 competencias, distribuidas en cinco categorías. ...
... La comunicación efectiva es crucial para el buen funcionamiento del laboratorio, especialmente cuando se trata de compartir conocimientos técnicos y operativos. Según (Ericsson, 2024), la transferencia de conocimiento es fundamental en ambientes de alta complejidad como los laboratorios clínicos. En este caso, los niveles de competencia más bajos podrían limitar la efectividad del equipo, afectando la productividad y la calidad del servicio. ...
competencias del personal del laboratorio clínico en un centro de salud materno infantil, dependiendo de los objetivos y necesidades específicas de la organización. El objetivo del estudio fue exponer las competencias, habilidades técnicas, destrezas interpersonales y otros aspectos relevantes del perfil profesional del talento humano que labora en el laboratorio clínico en el Hospital Materno Infantil "Orama González de Durán”. Amparada por el enfoque cualitativo, se contrastó de acuerdo a la literatura las características del perfil de competencias del personal de laboratorio clínico, lo cual se sustentó en el método método fenomelógico-hermeneútico un diseño descriptivo-interpretativo. Los hallazgos revelaron que el personal debe combinar conocimientos técnicos avanzados con habilidades interpersonales, compromiso ético, y tolerancia a la presión. Entre las competencias destacadas están la orientación al cliente, gestión de calidad, bioseguridad y trabajo en equipo. Las reflexiones develan que el personal de laboratorio clínico en un hospital materno infantil necesita combinar habilidades técnicas y habilidades interpersonales para garantizar la calidad de los servicios y los resultados y brindar la mejor atención posible a los pacientes y sus familias, para ello es esencial la comprensión de los roles y responsabilidades de cada miembro del equipo y la importancia del control de calidad para garantizar el éxito en la atención de la salud. estas competencias son esenciales para brindar atención de calidad y responder a las exigencias del entorno clínico.
... The minimum number of procedures should be determined in the local hospital protocol. According to the literature, proficiency in a real-world setting of the ultrasound-guided cannulation and correct performance of the Seldinger technique was achieved after conducting 10-30 procedures under supervision [89,[105][106][107]. The guidelines of the European Anesthesia Society regarding the perioperative use of ultrasound-guided vascular access recommend performing at least 30 successful procedures within 12 months of completing the theoretical-practical course and with a low complication rate in order to establish competency [108]. ...
The use of midline catheters and long peripheral catheters, as an alternative to short peripheral catheters, has become increasingly common, mainly due to their prolonged dwell time. This, in turn, improves patient experience, increases the efficiency of medical staff and reduces healthcare costs. Nevertheless, the introduction of midline catheters into the healthcare system requires structured, evidence-based, education and training, which allows for acquiring the skills necessary for their insertion and proper care. Proper implementation and improvement of clinical practices reduces the risk of complications, improves the quality of care and increases the effectiveness of medical procedures. The presented paper summarizes the characteristics of midline catheters, their indications and the benefits of their use. The authors particularly emphasized the need for effective training of medical professionals, especially in facilities where the staff lacks experience in working with this type of vascular access. Furthermore, the review discusses the proposed structured educational program, based on current scientific evidence and is designed to provide safe and effective midline catheter insertion in clinical practice.
... Those who can remember 12 or more digits indicate that they have exceeded the basic capacity limit through chunking strategies (such as encoding as dates or regular sequences); those who can remember less than 12 digits may rely on mechanical memory, reflecting insufficient chunking ability or lower efficiency in resource allocation. The resource allocation theory (Baddeley, 2000) further supports this threshold: cognitive resource consumption increases with the load of digits, and 12 serves as the upper limit of memory span after strategy optimization in behavioral research (Ricker et al., 2010;Ericsson, 2004), which not only conforms to the derivation of "4 core chunks × 3 digits/chunk" in Cowan's revised theory but also aligns with the sudden increase in error rate in the preexperiment, marking the saturation critical value of individual resource allocation (Norris and Kalm, 2021;Norris et al., 2020). ...
Introduction
Short-term memory poses a significant challenge, involving complex processes of image perception, memory formation, and execution. However, the mechanisms underlying the formation, storage, and execution of short-term memory remain poorly understood.
Methods
In this study, 41 healthy college students participated in a memory challenge test designed to investigate these processes. Functional near-infrared spectroscopy (fNIRS) was employed to measure dynamic changes in hemoglobin concentrations in specific cortical regions, while facial expressions and vital signs were recorded in real-time during the tests.
Results
The results revealed heightened activity in the inferior prefrontal gyrus, visual association cortex, pre-motor cortex, and supplementary motor cortex. Functional connectivity between these regions was significantly enhanced during the tasks, and inter-group differences decreased over time. Participants with superior short-term memory exhibited lower levels of negative emotional expressions and higher heart rates compared to those with weaker memory performance. These findings suggest that cortical interconnectivity and adequate cerebral blood oxygenation play critical roles in enhancing short-term memory capacity. This has important implications for education, as it highlights strategies for cultivating attention, training memory skills, and improving memory integration abilities.
... Immersive Virtual Reality (iVR) technology is revolutionizing medical education and surgical training and can potentially mitigate some of the challenges associated with traditional surgical training (Hasan et al. 2022). This modality allows for a purposeful and deliberate approach to education and yields a superior approach to gaining mastery of a topic (Ericsson 2004). Multiple studies have demonstrated the impact iVR can have on resident education and understanding some of the nuances of each technical approach Feeley et al. 2021;. ...
Successful orthopedic training includes mastering the orthopedic principles while developing a high level of surgical skills. Gaining experience and repetitions with these techniques can be particularly challenging for junior orthopedic residents, who typically have limited time in the operating room. There is a need to improve the education approach for junior orthopedic residents, and some residency programs have begun exploring the possibility of using virtual reality to augment orthopedic surgical training. Immersive Virtual Reality (iVR) technology is revolutionizing medical education and can potentially mitigate some of the challenges associated with traditional surgical training. This paper aims to describe how iVR training enhanced the skills of a first-year orthopedic surgery resident through a narrative review of their experiences. The resident participated in a comprehensive iVR training program (PrecisionOS™ iVR system) where the resident completed a learning curriculum of all-encompassing modules focusing on basic anatomy, surgical approaches, individual procedure techniques, and more. Utilizing iVR training allowed the resident to get real-time feedback, learn the anatomy, and also master the steps of different procedures before stepping into the operating room. The repetitive nature of iVR with the constant feedback allowed the resident to refine their technical skills, and with time, the steps became muscle memory. The resident observed a noticeable improvement in the overall efficiency and mastery in performing orthopedic procedures. From the attending’s standpoint, the guided preoperative preparation increased the trust and confidence in the resident, as the attending was able to give real-time feedback during the iVR module, making active changes and modifications. If there was a mistake made in the iVR space, it was very easy to reset the step and repeat it, and there was never any risk to the patient. In the experience of this resident, Immersive Virtual Reality (iVR) can be a helpful tool for a junior orthopedic surgery resident. It provides the resident with an opportunity to learn the surgical workflow and increase surgical efficiency in a safe and cost-effective environment.
... Practice (action) in behavior occurs when someone has passed two domains first, namely knowledge and attitude. After passing the previous two stages, a person will practice or carry out what is known and responded to (considered good) (Ericsson, 2004). Medicine is an irreplaceable part of health. ...
People generally carry out treatment independently and go to the doctor. Dagusibu is good and correct management of medicines in the household, namely getting, using, storing and disposing of. The aim of this research is to determine the relationship between knowledge and the behavior at students SMK Swasta Arjuna about DAGUSIBU (Get, Use, Save, Dispose) of drugs. This research is a correlation research method with a cross sectional survey approach, a correlation study. The total sample was 76 respondents, sample selection was carried out using the purposive sampling method with the Spearman Rho test. The research results showed that the majority of respondents were 16 years old, 41 respondents (53.9%), 70 respondents (92.1%). The majority of students SMK Swasta Arjuna Laguboti knowledge about Dagusibu was good knowledge, namely 51 respondents (67.1%) and 23 respondents (30.3%) had sufficient knowledge. The behavior at students SMK Swasta Arjuna about the use of DAGUSIBU had positive behavior of 48 people (63.2%) and negative behavior of 28 people (38.8%). There is no relationship between knowledge and the behavior at students SMK Swasta about DAGUSIBU (Get, Use, Save, Dispose) of drugs with a p value: 0.284. In this research, it is hoped to increase knowledge and behavior about Dagusibu medicine so that students SMK Swasta Arjuna Laguboti become people who behave appropriately in Dagusibu medicine.
... [8][9][10] Clinical skills competence is developed through deliberate practice, or focused, repetitive practice with assessment and feedback to guide students' continued improvement. 11,12 Simulation allows students to practice until they reach competence, unrelated to the number of cases that present requiring a procedure. Simulation supports competency-based veterinary education and mastery learning, or the idea that all students should achieve a defined level of aptitude, although the time for each student to reach that level may vary. ...
Left displaced abomasum (LDA) is a common condition in dairy cattle where the abomasum dilates and migrates to the left side of the abdomen. This condition causes significant economic losses for farmers and can result in life-threatening complications, so it is critical that veterinary students be taught to surgically correct a LDA before graduating and entering food animal practice. Models have been successfully used to teach students to perform other surgical procedures, but limited models exist to teach surgical skills to prospective dairy veterinary students. This study sought to develop and validate a bovine LDA reduction model and scoring rubric using a validity framework consisting of content evidence (expert opinion), internal structure evidence (reliability of rubric scores), and evidence showing the relationship with other variables (comparing expert to novice performance). Experienced veterinarians ( n = 12) and novice veterinary students ( n = 30) surgically deflated and reduced the model's LDA while being recorded. Videos were scored by a blinded expert. Participants completed a survey afterward. All veterinarians reported that the model was suitable for use in teaching and assessing students, offering content evidence for validation. Scores produced by the checklist had good reliability (α = .886), offering internal structure evidence. Veterinarians achieved higher checklist ( p = .025) and global rating scores ( p = .005) than students, offering relationship with other variables evidence. The development and use of food animal models promotes students’ development of competence in performing food animal procedures, leading to better qualified new graduates entering food animal practice. The use of models also protects animal welfare during students’ training.
... It could also be that improved equanimity is simply harder to maintain without consistent effort. Indeed, it has been noted [30] that deliberate practice can lead to a rapid development in skills but early progress can plateau [100], thus ongoing and committed training is likely required to ensure further development. This ethos is of course already enshrined in the TMAs. ...
The work of psychotherapy demands much of those who engage in it. Compassion provisioned by therapists requires varying competencies, yet remains a highly embodied and enactive endeavour. Therapist skill can be cultivated in this area and enhanced through a variety of body-mind trainings, including various forms of therapist personal practice. However, much clinical training/continued professional development centres on education workshops, emphasising knowledge above skill. Given this we present feasibility data from two deliberate practice/procedural learning, martial arts-based radically embodied compassion workshops aimed at enhancing therapist courage. Our findings show that conducting such training is feasible, with those attending able to participate in each practice. Participant self-report suggests the workshops can result in significant personal benefit, are able to deepen attendee understanding of compassion focused therapy and lead to an enhanced sense of how to apply it. Via self-report pre, post and 3-month after the workshops, significant beneficial changes in overall total clinical distress tolerance as well as specifically in absorption (the level of attention absorbed by distressing emotions) were shown. Beneficial changes were also noted in experiential acceptance and in total general equanimity pre and post workshops. We discuss limitations of the current study and potential future work that could follow from it, before concluding that training in this way represents an important first step in delineating a novel approach to therapist self-development. Practices drawn from traditional martial arts may be well suited to providing the context, relational safety and necessary skills for therapist development, in terms of enhanced distress tolerance and management of the self, to occur.
... In other words, professional development and learning is the result of conscious and deliberate changes in certain aspects of practice (Ericsson, 2006). Optimal professional performance can be achieved by structured training of the elements that work in deliberate practice so that they become a regular part of everyday work practice (Ericsson, 2004). Deliberate practice leads to cognitive, perceptual, physiological, neurological and anatomical changes necessary for the acquisition of complex, domain-specific professional skills (Ericsson, 2017). ...
In the last 30 years, career-long professional development and learning, in-service teachers’ professional development and adaptive teacher expertise have been key concepts associated with positive educational changes. Career-long professional learning and development is defined as a collection of lifelong processes and activities aimed at improving teaching competencies and the general professional well-being of teachers, and consequently the learning of students. In-service teachers’ professional development is defined as a time-limited series of activities with clearly defined teachers’ learning outcomes. The purpose of career-long professional development and learning and in-service teachers’ professional development as its component is to contribute to the development of adaptive teacher expertise. As an adaptive expert, the teacher is skillful in finding creative solutions to everyday challenges in the classroom, while applying a research-reflexive approach to teaching and thus building a flexible base of professional competences. Professional vision is one of the most important components of adaptive teacher expertise, which is defined as the ability to observe and interpret selected elements of teaching practice, as well as make decisions on how to act based on what is observed. In order to achieve the optimal development of these competences, it is necessary to create a stimulating environment in which teachers will prepare, perform and video-record classes, reflect on them and receive feedback on their teaching within a learning community. Since the usual in-service teachers’ professional development in Croatia does not correspond to the above-mentioned guidelines, this paper aims to describe new possibilities of developing adaptive teacher expertise in professional development programs with the use of classroom video.
... Training standardized patients is one of the key challenges in pharmacy simulation regarding (1) p-value of Mann-Whitney U test (Virtual Simulation vs. In-person simulation); p-value < 0.05 was considered as statistically significant Table 6 Students' perception of a virtual and in-person simulation in each group p-value of Wilcoxon signed-rank test (Virtual Simulation vs. In-person simulation); p-value < 0.05 was considered as statistically significant acting according to the script to achieve optimal reliability. Dealing with standardized patients requires coordination, consent, practice, feedback, and mentoring, which is time-consuming [24,25]. In this context, the course instructors encountered several challenges in optimizing standardized patients for exercises in terms of training and orientation, which required more time [26]. ...
Background
Drug information training is restricted to pharmacy students due to the lack of opportunities for training and the inadequate number of drug information centers. Drug information simulation requires manpower and is time-consuming to arrange. MyDispense (MD) is widely accepted by numerous pharmacy schools and plays a major role in training students for various courses in the pharmacy curriculum. However, the students’ performances and perceptions of MD in drug information training involving nonjudgmental queries are yet to be established.
Objective
To compare the student’s success and perceptions of virtual versus in-person simulation in providing drug information.
Methods
A cross-over study design was used to compare student performance and perception of virtual and in-person simulation. A total of one hundred and forty-nine students consented to participate in the study. They were randomly allocated, with 75 assigned to the MD group and 74 to the in-person simulation group for exercise (1) Then, the students crossed over to in-person simulations and MD for exercise (2) A 5-point Likert scale questionnaire consisting of ten items was developed and validated to assess their perception regarding the learning experience of drug information exercises. Simple logistic regression was used to compare the students’ success rate, and the mean value of students’ responses was compared using non-parametric tests.
Results
In exercise 1, a significant association of student success with MD was observed with task 2 (Identify the patient’s background; p = 0.001) and task 3 (Identify background information of the drug information query; p = 0.002). The students expressed a significantly higher confidence level (p = 0.000) when dealing with virtual patients, as reflected in their success rate regarding the identification of the background of the patient and the nature of the drug information question during exercise 1. However, students’ responses to the item related to the confidence level had no significant difference in exercise 2 (p = 0.382). Further, in-person and MDs had no significant differences regarding student perception of the remaining tasks in both exercises. Also, the student performances were comparable between virtual and in-person simulation in exercise 2.
Conclusion
The students’ performances and perceptions were comparable between virtual and in-person simulations at different times. Therefore, MD can be implemented to train the students regarding drug information services and handle nonjudgmental queries at community pharmacies.
... initial design of the VR simulation design was guided by a conceptual framework integrating several educational theories. the theory of deliberate practice was used to structure learning objectives around progressive skill acquisition to enhance competency in high-stakes settings [46]. adult learning theory informed scenario design to ensure self-directed, clinically relevant learning experiences to promote engagement and retention [47]. ...
Background
Team leadership during medical emergencies like cardiac arrest resuscitation is cognitively demanding, especially for trainees. These cognitive processes remain poorly characterized due to measurement challenges. Using virtual reality simulation, this study aimed to elucidate and compare communication and cognitive processes-such as decision-making, cognitive load, perceived pitfalls, and strategies-between expert and novice code team leaders to inform strategies for accelerating proficiency development.
Methods
A simulation-based mixed methods approach was utilized within a single large academic medical center, involving twelve standardized virtual reality cardiac arrest simulations. These 10- to 15-minutes simulation sessions were performed by seven experts and five novices. Following the simulations, a cognitive task analysis was conducted using a cued-recall protocol to identify the challenges, decision-making processes, and cognitive load experienced across the seven stages of each simulation.
Results
The analysis revealed 250 unique cognitive processes. In terms of reasoning patterns, experts used inductive reasoning, while novices tended to use deductive reasoning, considering treatments before assessments. Experts also demonstrated earlier consideration of potential reversible causes of cardiac arrest. Regarding team communication, experts reported more critical communications, with no shared subthemes between groups. Experts identified more teamwork pitfalls, and suggested more strategies compared to novices. For cognitive load, experts reported lower median cognitive load (53) compared to novices (80) across all stages, with the exception of the initial presentation phase.
Conclusions
The identified patterns of expert performance — superior teamwork skills, inductive clinical reasoning, and distributed cognitive strategiesn — can inform training programs aimed at accelerating expertise development.
... Until now, the debriefer training course for simulationbased healthcare educators is available through workshops, courses, fellowship programs, and peer coaching [26,27]. While these methods provide important didactics and valuable experience, one-time professional development models and opportunistic experiences are not known to have a significant impact in improving professional performance which is more closely related to hands-on engagement with feedback during training [28,29]. ...
Purpose: Debriefing after simulation-based healthcare education (SBHE) is challenging. Educators’ debriefing skills are essential to the success of learning. For debriefing skill training, we designed a simulation course with the standardized learner (SL) through video conference. The purpose of this study was to describe the implementation process of the SL simulation course and evaluate its effectiveness on educators’ self-confidence and debriefing skills.Methods: This simulation course involved six trainees and two trainers. After watching a 5-minute sample video of SBHE, each trainee conducted their role as a debriefer in this video and the trainer acted as a learner (SL) in this video. Following each simulation, individual feedback by the trainer was immediately implemented. To evaluate the course’s effectiveness, trainees’ self-confidence questionnaire was collected, and objective structured assessment of debriefing (OSAD) scores were evaluated.Results: After completing five SL simulation sessions in 2 weeks, the trainees’ self-confidence level and OSAD scores improved significantly (estimate=0.114, standard error=0.020, p<0.001, and p=0.006).Conclusion: This debriefer training course using SL simulation via video conference could improve self-confidence and debriefing skills of trainees. This SL simulation can be used as a new and flexible method for training debriefers.
... 4 Clinical skills are learned through deliberate practice, or the repetitive practice of the skill with specific feedback to guide future performance. 5,6 Models play an important role in teaching clinical skills, allowing students to practice procedures in a controlled and safe environment while developing muscle memory and confidence. The use of models supports the three Rs (replacement, reduction, and refinement) by replacing select use of live animals for invasive procedures, reducing the total number of animals required for learning, and refining student skills before live animal practice. ...
Diagnostic sample collection, including venipuncture, is critical to diagnosing and treating cattle. Clinical skills models permit learners to practice a skill and improve their competency before performing the skill on a live animal; however, relatively few bovine models exist. This study aimed to develop and validate a bovine coccygeal venipuncture model and rubric for teaching and assessing veterinary students using a validation framework consisting of content evidence, internal structure evidence, and relationship with other variables evidence. Veterinary students ( n = 38) and experienced veterinarians ( n = 12) performed venipuncture on the model while being video recorded. Recordings were scored blindly using a six-item rubric and a global rating score. Time to perform the task and total number of needle sticks were recorded. Veterinarians reported that the model was suitably realistic for students to learn to perform the task ( content evidence). Rubric scores had acceptable reliability ( a = .783, internal structure evidence). Veterinarians received higher rubric scores and used fewer needle sticks to complete the task ( p = .033 and .047, relationship with other variables evidence—level of training). Students’ survey responses were very positive. The evidence collected in this study supported validation of the model and rubric. The use of validated models and rubrics allows educators to teach and assess skills reliably, and the model allowed students to practice the skill repetitively, reducing the use of live animals. Additional studies would be necessary to evaluate the model for use in teaching veterinary technicians, extension agents, and livestock producers to perform this task.
... Clinical skills are learned through deliberate practice, which consists of repetitive practice of a task with specific feedback, leading to better skills performance. 14,15 Models allow students to practice many times to refine their techniques and gain competence and confidence before performing procedures on live animals. ...
Bovine practitioners expect new graduates entering clinical practice to be able to place a caudal epidural. Teaching this task on models facilitates scheduled training sessions and sufficient practice to reach competency. This study sought to create and validate a bovine caudal epidural model and scoring rubric using a framework of content evidence, internal structure evidence, and relationship with other variables evidence. Veterinarians ( n = 11) and students ( n = 40) were video recorded while placing a caudal epidural on the model. Recordings were scored by a blinded rater. Participants completed a survey evaluating the model's features, ease of use, and anticipated best use. Veterinarians reported that the model was helpful for students to learn and practice the task and that the model had sufficient landmark features and realism ( content evidence). Rubric scores achieved acceptable internal consistency after one item was dropped ( α = .736; internal structure evidence), and there was no significant difference between veterinarians’ and students’ performance scores on the model ( relationship with other variables evidence). Survey feedback indicated the task on the model was simple, allowing students to achieve scores similar to those of veterinarians. Therefore, the model and rubric were not able to be validated using this study's validity framework. However, there are simple clinical skills models used in veterinary education and other health care fields, and research suggests that learning does take place on these models. Educators must consider whether simple models that are helpful for students to practice their skills may still have value, even if they are not able to be validated.
... Cross-utilization should not result in a decline in surgical standards or treatment quality; this is something that must be emphasized. Appropriate training, adherence to standards and ongoing evaluation are required to keep specialized and transferable skills at a high level of expertise [9]. When carried out germanely, quality improvement is a net benefit of the crossutilization of nurses in the ICU healthcare setting. ...
... Current pathways for practicing surgeons to learn these techniques include one-on-one mentoring in clinical settings, hands-on courses organized by surgical societies (e.g., SAGES), and workshops offered by the industry. While these opportunities often provide a personalized "master-to-trainee" approach, they could lack standardized validation and are typically sporadic, without key components of deliberate practice such as supervised repetition [37]. Emerging remote and deferred feedbackbased initiatives hold promise for continuous laparoscopic training, including intracorporeal suturing and anastomosis Content courtesy of Springer Nature, terms of use apply. ...
Background
The benefits of the totally laparoscopic right hemicolectomy have been established, but its adoption has been limited by the challenges of intracorporeal suturing. While simulation is effective for training advanced surgical skills, no dedicated simulation-based course exists for intracorporeal ileo-transverse anastomosis (ICA). This study aimed to develop and validate a simulation module for training in ICA.
Methods
This study employed a proof-of-concept design for an educational tool. Key aspects of the anastomosis were identified using the team’s surgical experience, surgical videos, and existing evidence. Surgeons were recruited to test and refine successive simulation models through an iterative process until a functional prototype was achieved and assessed. Subsequently, surgeons with varying experience levels were invited to perform an ICA in the model. Performance was evaluated by two blinded surgeons through video recordings, utilizing a modified Objective Structured Assessment of Technical Skills (OSATS), a Specific Rating Score (SRS), and operative time measurements. Non-parametric descriptive and analytical methods were applied, with results presented as median [IQR].
Results
An ex vivo based model was developed. Seventeen participants evaluated the model. Eighty-three percent declared acceptable or maximum fidelity regarding the colon. Resemblance to the surgical scenario in terms of ergonomic and anatomical similarity was highlighted. All participants found the model useful to train intracorporeal suturing. Thirteen subjects performed the ICA. Experts achieved significantly higher OSATS scores (22.3 [22–22.5] vs 18 [16–19.5]; p = .013), exhibited a trend toward higher SRS, and obtained shorter operative times (21.5 vs 36 min; p = .039).
Conclusion
An ex vivo simulation module for ICA was developed, demonstrating acceptable fidelity in replicating the surgical environment. The simulated scenario could successfully distinguish between levels of surgical experience, as evidenced by significant differences in OSATS scores and operative times, thereby confirming its construct validity.
Unlike static comments, which are typically located below online videos, live comments affect consumers’ video-watching experiences in real time and may influence their evaluation of the video in distinct ways. Despite the significance of live comments, few studies have explored the differentiated effects of live comments vs. static comments on user evaluation of online videos. Utilizing a dataset comprising approximately two million pieces of textual data from a leading Chinese online video platform, our findings reveal substantial differences between the effects of live and static comments, with these effects varying by video type (informational versus emotional) and showing notable changes during health threats. This study examines the differential impact of live vs. static comments, providing empirical evidence for distinct information processing pathways under varying time constraints. Our results shed light on the underlying mechanisms responsible for the diverse effects of different forms of social interaction, offering valuable theoretical insights. They also have managerial implications regarding how online video platforms can facilitate engagement among viewers and between video creators and their audiences.
Introduction: Mastering microsurgery requires advanced fine motor skills, hand–eye coordination, and precision, making it challenging for novices. Robot-assisted microsurgery offers benefits, such as eliminating physiological tremors and enhancing precision through motion scaling, which may potentially make learning microsurgical skills easier. Materials and Methods: Sixteen medical students without prior microsurgical experience performed 160 anastomoses in a synthetic model. The students were randomly assigned into two cohorts, one starting with the conventional technique (HR group) and one with robotic assistance (RH group) using the Symani surgical system. Results: Both cohorts showed a reduction in procedural time and improvement in SAMS scores over successive attempts, with robotic anastomoses demonstrating a 48.2% decrease in time and a 54.6% increase in SAMS scores. The decreases were significantly larger than the RH group (p < 0.05). The quality of the final anastomoses was comparable in both groups (p > 0.05). Discussion: This study demonstrated a steep preclinical learning curve for robot-assisted microsurgery (RAMS) among novices in a synthetic, preclinical model. No significant differences in SAMS scores between robotic and manual techniques after ten anastomoses. Robot-assisted microsurgery required more time per anastomosis, but the results suggest that experience with RAMS may aid in manual skill acquisition. The study indicates that further exploration into the sequencing of robotic and manual training could be valuable, especially in designing structured microsurgical curricula.
The present study investigates the performance of local government in the implementation of plans and projects and the role of perceived effects of villagers from these plans and projects for their participation in the process of the spatial evolution of rural settlements in the Esfandagheh district. This research is quantitative in scope; Which has studied the effective and influential variables of this research by the descriptive-analytical method and questionnaire tools. The research results indicate a positive and significant relationship between the performance of local government variables and four mediating environmental effects - ecological, social, economic, and physical - infrastructure perceived from plans and projects. Confirmed the relationship between local government and their participation in spatial change with the mediating role of environmental-ecological, social, and physical-infrastructural effects perceived from plans and projects. However, they did not confirm the relationship between local government and their participation in spatial change with the mediating role of perceived economic effects of plans and projects. In other words, the implementation of spatial transformation plans and projects in the economic field has not involved villagers' participation in this field. In general, the research findings showed that local government with the mediating role of environmental-ecological, social, and physical effects of villagers' perceptions of plans and projects on their participation in three dimensions of environmental-ecological, social, and structural spatial evolution. It has had a positive and significant effect.
Virtual Reality (VR) has emerged as a transformative tool in medical education and training, revolutionizing the way physicians and students acquire and refine crucial skills. This paper aim into the multifaceted applications of VR technology within the healthcare sector, particularly focusing on its integration into medical education. Over time, major VR-based companies have developed innovative products that seamlessly blend 360-degree video and interactive 3D content to create immersive learning experiences for healthcare professionals.
The utilization of VR simulations enables practitioners to engage in lifelike scenarios, allowing them to practice intricate procedures in a risk-free environment. This approach not only enhances clinical skills but also provides invaluable opportunities for receiving real-time feedback on performance and improving proficiency. Moreover, the incorporation of VR in medical education extends beyond physicians, reaching into nursing education, where its benefits are becoming increasingly evident.
Through an exploration of current trends and advancements in VR technology, this paper elucidates the pivotal role of VR in shaping the future of medical education and healthcare training. By facilitating experiential learning and fostering a culture of continuous improvement, VR stands as a cornerstone in the evolution of healthcare education, promising enhanced patient care and safety through the cultivation of competent and confident healthcare professionals.
Hypothesis
Virtual reality (VR) simulation has been established as an effective method of supplementing traditional surgical training. Learning curves can analyze skill acquisition over time in VR settings. Although previous studies explored learning curves of mastoidectomy performances on single specimen, this study analyzed learning curves on anatomically different virtual temporal bones across three expertise levels (novice, intermediate, and expert).
Methods
Thirty participants were divided into three groups: 10 medical students (novice), 10 ear, nose and throat (ENT) registrars (intermediate), and 10 senior ear surgeons (expert). They performed mastoidectomy on eight anatomically different temporal bones on the University of Melbourne Temporal Bone Surgery Simulator. A blinded senior ENT surgeon assessed the final products of the dissections using the Melbourne Mastoidectomy Scale (MMS). Learning curves of MMS scores, number of strokes, average force, drilling time, and total time were compared between groups using Friedman tests. Within-group analyses were conducted with Wilcoxon signed-rank tests.
Results
All performance metrics showed significant differences across all groups. Only comparison between intermediate and expert groups for average force was not significant. Within-group analyses showed significant differences in expert group for total and drilling time, intermediate group for average force, and novice group for total time. Individual learning curves of intermediate group demonstrated varied learning behavior.
Conclusions
Trainee performance was not seen to reach the level of experts after eight repetitions on anatomically different specimens. Enhancing training with individualized feedback and increased repetitions may optimize skills acquisition.
Objective
To describe a structured approach to the development of a mitral valve repair (MVR) program for dogs with myxomatous mitral valve disease (MMVD) and to document the change in short term outcome over time.
Study design
Clinical prospective study.
Animals
Dogs ( n = 132) with MMVD undergoing MVR at a single hospital.
Methods
Using a carefully structured multidisciplinary approach to patient selection, surgical treatment, and postoperative care that incorporated both “reflective” and “deliberate” practice, we embarked on an MVR program alongside our pre‐existing open heart surgery program. Data were gathered for the first 132 dogs undergoing MVR in this program (between July 2015 and November 2022). Short‐term survival was defined as dogs that were discharged from the hospital. The dogs were divided into four groups of equal size based on chronological order and the data within each group compared using descriptive statistics.
Results
The breeds most represented were Cavalier King Charles Spaniels (CKCS) and Chihuahuas. The MMVD was categorized clinically as stage D in 36/132 (27%), stage C in 88/132 (67%) and stage B2 in 8/132 (6%) of affected dogs. Overall, 107/132 (81%) of the dogs survived to discharge. A consistent trend of improved short‐term outcome was observed, with survival rate of 22/33 in the first quartile, 27/33 in the second quartile, 28/33 in the third quartile, and 30/33 dogs in the fourth quartile.
Conclusion
A structured organized approach by a team of consistent personnel resulted in an improvement in outcome over time. This improvement most likely reflected improvement in both technical and non‐technical skills within this complex sociotechnical environment.
Clinical significance
What constitutes an acceptable performance for MVR in the dog has not been defined so the number of cases that constitute the “learning curve” during program development and the number of cases required in the “skills maintenance” phase remain unknown. The data reported here, however, describe the level of organizational commitment and the case throughput required to begin the process of establishing a successful MVR program and as such, should be useful to any team considering this therapy.
Social capital is defined as a collection of relationships, networks, trust, needs, and participatory systems in a society that, when increased, improve the society's ability to face challenges and enhance the living conditions of its members. On the other hand, setting management drivers at the level of territorial governance requires an approach based on these aspects of social capital, especially the social capital of the local community, to achieve participatory governance of the territory. Therefore, projects such as the sustainable development plan for rural systems, which promote and optimally utilize the capital of local communities, have been implemented to improve the governance system of the territory. Accordingly, this research has analyzed intragroup social capital before and after the implementation of the plan in three villages-Eskelabad, Eslamabad Kaleh-Espid, and Chah Ahmad Asli in Taftan County-which were among the target areas of this plan. Given the importance of participatory management and strengthening social capital, analyzing the link between trust and participation among individuals in these villages is essential. As a result, the social network analysis method has been used to examine the links of trust and participation among the members of the targeted rural development funds. Sampling in each village included the head members of each fund, comprising 30 people per fund. The results of the network analysis before the implementation of the plan indicated a low level of social capital among the local community. Additionally, a relatively large distance in relationships among the fund members was observed before the implementation of the plan. Conversely, the results of the network analysis after the plan's implementation showed that these indicators followed a positive trend. The speed of information circulation among individuals increased significantly, while distances were reduced. Consequently, it can be stated that implementing the development and progress plan for rural systems in the county under study has led to increased unity among villagers and improved intragroup social capital. In other words, improved communication has created opportunities for enhancing social welfare and expanding trust and participation among village residents.
Introduction Paramedics handle diverse medical and trauma cases, where any lapse in competency can compromise patient safety. Student paramedics must meet high standards set by oversight bodies to protect both the profession and the public. Growing evidence indicates that simulation facilitates attainment and reinforcement of clinical competencies. However, limited evidence explores the impact of simulation and debriefing on developing clinical competence in undergraduate paramedicine students. Aim This study aimed to evaluate the association between weekly practice session performance and summative practical exam outcomes, assessing how simulation-based practice supports the development of clinical competence among paramedicine students. Methods A retrospective analysis of performance-based assessment data (2019–2024) in a university paramedicine program evaluated the role of high-frequency simulation. Second-year students participated in weekly three hour simulated practice sessions and a summative practical exam, with performance assessed using the Clinical Competence Assessment Tool (CCAT). Practice session data were grouped into tertiles to assess trends. Pearson’s correlation measured the association between practice frequency and exam outcomes, paired samples t-tests evaluated performance progression, and hierarchical regression identified significant predictors of exam outcomes. Results Data from 305 students and 1,251 practice scenarios revealed a significant positive correlation between practice frequency and exam performance (rs = 0.257, p < 0.001). Clinical competence scores improved progressively across the trimester, with the strongest correlation observed in the final tertile (rs = 0.229, p < 0.001). Earlier tertiles showed weaker but statistically significant correlations (p < 0.05). A performance dip in 2020 due to reduced simulation exposure during COVID-19 further highlighted the critical role of consistent, high-frequency practice in fostering competence and exam success. Conclusion This study demonstrates the value of structured, high-frequency simulation and debriefing in enhancing clinical competence and exam performance. The findings underscore the importance of consistent practice, particularly in the final trimester weeks, supporting its integration into paramedicine curricula to ensure readiness for real-world practice and sustained competence.
Pediatric resuscitations involving shock and trauma are rare but they are high-stakes events in the pediatric emergency department (ED). Effective use of point-of-care ultrasound (POCUS) can expedite diagnosis and treatment in such cases. This study aimed to assess the impact of a longitudinal pediatric emergency medicine simulation curriculum and high-fidelity POCUS simulator on residents’ clinical practice, comfort level, and motivation to learn resuscitative ultrasound.
This mixed-methods study involved 12 pediatric emergency medicine residents who participated in a 12-month simulation curriculum integrating resuscitative ultrasound. The POCUS simulator was integrated and made available for use during all simulations. Assessment and program evaluation occurred at multiple levels, according to Kirkpatrick’s hierarchy, using both qualitative and quantitative methods. The residents were surveyed at baseline, 4, 8 and 12 months. Semi-structured interviews were conducted at the end of the 12-month study period.
Twelve residents participated in 23 simulation cases over the 12-month longitudinal curriculum. The hybrid POCUS simulator was used by participants in 18/23 (78.2%) cases. Comparing pre- and post-curriculum changes, large effect sizes were seen in residents’ comfort using ultrasound in resuscitation (including in cases of trauma and undifferentiated shock). Accordingly, the mean number of POCUS scans performed per resident clinically on shift increased from a mean (SD) of 5.7 (± 2.3) scans/month to 12.4 (± 5.1) scans/month. Qualitative analysis highlighted several themes, including the value of simulation for teaching the integration of resuscitative ultrasound in high-acuity low-occurrence events and the effect of repeat exposures to resuscitative ultrasound.
Our study demonstrated that a longitudinal, simulation-based curriculum focused on resuscitative ultrasound increased residents’ confidence, their motivation and likelihood of using these skills in the clinical setting. Repeated simulation exposures to resuscitative ultrasound can help participants translate this critical skill into use at the bedside, especially in high-acuity low-occurrence events.
Airway management skills are among the most critical life-saving skills that clinicians caring for neonates must attain. Developing proficiency in these skills is challenging and requires a thoughtful approach, especially in the current training environment with limited clinical experiences. Comprehensive airway training programs should incorporate a variety of learning activities that address each aspect of the skill development pathway and support the needs of different learners. Repetition of activities, opportunities for practice with feedback, and an effective learning environment are all factors that may enhance optimal skill development.
The Accreditation Council for Graduate Medical Education (ACGME) requires that neonatal–perinatal medicine (NPM) fellowship training programs document and attest to trainee competency in common procedures, such as neonatal tracheal intubation (TI). However, there are no published guidelines or evidenced based approaches for how competency in TI should be determined or evaluated. Given the possibility of long-term complications associated with TI, it is essential for patient safety that neonatologists can perform TI safely and effectively. This chapter reviews the strengths and shortcomings of methods historically and currently employed to assess competency in TI followed by a discussion of newer and future methods of assessment that may provide safer and more effective approaches to TI education and assessment. This chapter will describe pedagogical frameworks, data management, and TI equipment and tools that can augment existing TI curricula and assessment to provide more objective data when evaluating a clinician’s competency to perform lifesaving yet high-risk procedures.
Neonatal airway management is critically important for providers and trainees caring for neonates and infants in the delivery room and neonatal intensive care unit. The stakes for airway management procedures are high, as inadequate support may lead to hypoxemia, bradycardia, and even death. This chapter provides an overview of the comprehensive, state-of-the-art review of neonatal airway management covered in this text. Patient, practice, provider, and system factors important in neonatal airway management are each considered in detail. Key topic areas including airway management techniques, training, competency assessment, premedication, video laryngoscopy, laryngeal mask airway, and others are incorporated in this book, which provides a concise yet comprehensive summary of the current state of the field that will help guide patient management and stimulate investigative efforts.
Introduction: ‘Graduate on Time’ (GoT) for the Master of Surgery Programme at thirty percent is one of the attributes for shortage of surgeons in Malaysia. This literature review will provide the best evidence in medical education (BEME) to improve GoT for postgraduate training in surgery.
Methodology: Five hundred abstracts were searched and retrieved from PubMed and Google Scholar electronic databases. They were reviewed and screened against the inclusion and exclusion criteria. Out of a hundred and fifty articles summarised, ninety were included in this review.
Findings: Various themes were identified, then categorized according to the importance of ‘graduate on time’, impact of learning theories and factors that affecting performance on surgical training. The learning environment in the postgraduate training is very dynamic, different and more challenging than the undergraduate’s. The cause for low GoT is multifactorial, and the interventions should be targeted at different stages by various stakeholders. There is not enough evidence available for utility analysis to conclude the best method and selection process. However, there is promising evidence to support the inclusion of the Multiple Mini Interview (MMI), Situational Judgement Test (SJT) and Clinical Problem-Solving Test (CPST) in the selection process. The role for Motivated Learning Strategy Questionnaires (MSLQ) needs further evaluation.
Conclusion: A brief proposal based on BEME available has been developed to improve GoT with special focuses on developing a current postgraduate curriculum, strengthening the trainers, supporting the trainees and evidence-based selection process withing the context of Malaysian postgraduate training landscape.
Objective
To educate physician trainees using simulation on best management of children with autism spectrum disorder who have neurocognitive and behavioral challenges when experiencing acute illness.
Method
A simulation-based curriculum including baseline assessment, communication techniques, and use of calming resources was developed to educate residents in assessing children with sensory barriers. Traditional simulation and deliberate practice were used to teach this curriculum to second- and third-year pediatric and internal medicine-pediatric residents. Using alternating assignment, residents were placed into 3 groups: deliberate practice, traditional simulation-based debriefing, and control (no simulation training). The residents were assessed on the initial visit, 2 weeks and 4 to 6 months follow-up periods with a sensory assessment tool. Assessment scores were analyzed using a general linear mixed model with random intercept based on Poisson regression to approximate distribution of the total score.
Results
Forty-three residents participated: 46.5% men, 53.5% women. There were 15, 16, and 12 residents in the control, deliberate practice and traditional simulation groups, respectively. Both teaching styles showed improved performance at 2 weeks follow-up. In addition, these groups demonstrated higher performance when compared with the control group. We were able to show that resident physicians were able to learn important principles and retain them during 4 to 6 months follow-up. However, there was not a difference between 2 teaching styles both in improvement and retention.
Conclusion
Simulation education, both deliberate and traditional, can be used to enhance teaching of key components in assessing children with sensory and communication barriers, including those with autism spectrum disorder when presenting with acute illness.
Background
Motion-tracking has been shown to correlate with expert and novice performance but has not been used for skill development. For skill development, performance goals must be defined. We hypothesize that using wearable sensor technology, motion tracking outcomes can be identified in those deemed practice-ready and used as benchmarks for precision learning.
Study Design
At the ACS Clinical Congress, surgeons and surgeons in-training volunteered to wear motion-tracking sensors while performing intracorporeal suturing and knot-tying, laparoscopic pattern-cutting and simulated laparoscopic cholecystectomy. Coach raters evaluated the subjects using a modified SIMPL scale. Subjects were divided into two groups based on coach ratings, practice-ready and not practice-ready. Motion results were compared. Benchmark performance for each motion-tracking outcome of the simulated laparoscopic cholecystectomy was set at the median(+/-MAD) of the practice-ready cohort. For all subjects, each motion-tracking outcome was compared to the benchmark.
Results
94 subjects were recruited. 53 were rated at practice-ready. Differences between groups were identified in 2 of 10 metrics for intracorporeal suturing and knot-tying, 4 of 10 metrics for pattern-cutting, and 5 of 10 metrics for the laparoscopic cholecystectomy. Set benchmarks for the metrics were compared to each subjects’ score for all individual metrics. A not practice-ready individual was less likely to achieve the benchmarks.(χ ² = 55.48 p <.00001).
Conclusion
Wearable sensor technology can identify differences between surgeons rated practice-ready and not practice-ready. More importantly, motion metric results can be used to develop benchmarks for training endpoints. This will allow for development of an individualized report card and training protocol focused on areas in need of improvement instead of the current model of generalized training. Implementing such focused training may expedite competency and mastery of surgical skills.
The theoretical framework presented in this article explains expert performance as the end result of individuals' prolonged efforts to improve performance while negotiating motivational and external constraints. In most domains of expertise, individuals begin in their childhood a regimen of effortful activities (deliberate practice) designed to optimize improvement. Individual differences, even among elite performers, are closely related to assessed amounts of deliberate practice. Many characteristics once believed to reflect innate talent are actually the result of intense practice extended for a minimum of 10 years. Analysis of expert performance provides unique evidence on the potential and limits of extreme environmental adaptation and learning.
Theories arguing that specific skills are acquired through extended practice cannot easily account for some musicians’ ability to perform unfamiliar music without preparation at first sight (sight-reading). This study identified the source of individual differences in this ability among expert pianists by relating component abilities of sight-reading and biographical indicators of skill acquisition to actual sight-reading performance. Sixteen advanced pianists of comparable skill played music without rehearsal (sight-reading) and after brief rehearsal (accompanying). Performances were paced by a recorded melody line. Pianists then performed experimental tasks designed to capture isolated subskills of sight-reading such as improvisation, recall, and kinesthetic ability. Sight-reading and accompanying performance correlated significantly with performance on the component tasks and with interview data on subjects’ training background, including the accumulated amount of time spent with accompanying-related activities and the size of accompanying repertoire. After controlling for the effects of subskills, age, professional specialization, and an indicator of general pianistic skill, accumulated accompanying experience and size of accompanying repertoire still accounted for significant unique variance in sight-reading and accompanying performance. Individual differences in unrehearsed performance among expert pianists reflect the consequences of domain-relevant activities (accompanying) and deliberate skill-building efforts (increase in size of relevant repertoire).
Counter to the common belief that expert performance reflects innate abilities and capacities, recent research in different domains of expertise has shown that expert performance is predominantly mediated by acquired complex skills and physiological adaptations. For elite performers, supervised practice starts at very young ages and is maintained at high daily levels for more than a decade. The effects of extended deliberate practice are more far-reaching than is commonly believed. Performers can acquire skills that circumvent basic limits on working memory capacity and sequential processing. Deliberate practice can also lead to anatomical changes resulting from adaptations to intense physical activity. The study of expert performance has important implications for our understanding of the structure and limits of human adaptation and optimal learning. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Replies to H. Gardner's (see record
1996-10360-001) comments on K. A. Ericsson and N. Charness's (see record
1994-43905-001) review of the structure and acquisition of expert performance. In contrast to Gardner, they attribute differences to the individuals' history of relevant activities that differentially benefit the acquisition of associated skills. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Proposes a framework for skill acquisition that includes 2 major stages in the development of a cognitive skill: (1) a declarative stage in which facts about the skill domain are interpreted and (2) a procedural stage in which the domain knowledge is directly embodied in procedures for performing the skill. This general framework has been instantiated in the ACT system in which facts are encoded in a propositional network and procedures are encoded as productions. Knowledge compilation is the process by which the skill transits from the declarative stage to the procedural stage. It consists of the subprocesses of composition, which collapses sequences of productions into single productions, and proceduralization, which embeds factual knowledge into productions. Once proceduralized, further learning processes operate on the skill to make the productions more selective in their range of applications. These processes include generalization, discrimination, and strengthening of productions. Comparisons are made to similar concepts from previous learning theories. How these learning mechanisms apply to produce the power law speedup in processing time with practice is discussed. (62 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Two studies tested the theory of deliberate practice (K. A. Ericsson et al, 1993) and contrasted results with the sport commitment model (T. K. Scanlan et al, 1993a, 1993b). In Part I, international (mean age 25.6 yrs), national (mean age 24.0 yrs), and provincial (mean age 25.4 yrs) soccer and field hockey players recalled the amount of time they spent in individual and team practice, sport-related activities, and everyday activities at the start of their career and every 3 years since. In Part II, these activities were rated in terms of their relevance for improving performance, effort and concentration required, and enjoyment. A monotonic relationship between accumulated individual plus team practice and skill level was found. In contrast with Ericsson et al's findings for musicians, relevant activities were also enjoyable, while concentration became a separate dimension from effort. The viability of a generalized theory of expertise is discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This paper examines learning curves in the health care setting to determine whether organizations achieve performance improvements from cumulative experience at different rates. Although extensive research has shown that cumulative experience leads to performance improvement across numerous contexts, the question of how much of this improvement is due to mere experience and how much is due to collective learning processes has received little attention. We argue that organizational learning processes may allow some organizations to benefit more than others from equivalent levels of experience. We thus propose that learning curves can vary across organizations engaged in the same "learning task," due to organizational learning effects. To investigate this proposition, we investigate cardiac surgery departments implementing a new technology for minimally invasive cardiac surgery. Data on operative procedure times from a sample of 660 patients who underwent the new operation at 16 different institutions are analyzed. The results confirm that cumulative experience is a significant predictor of learning, and further reveal that the slope of the learning curve varies significantly across organizations. Theoretical and practical implications of the work are discussed.
A new theory of the development of expertise in medicine is outlined. Contrary to existing views, this theory assumes that expertise is not so much a matter of superior reasoning skills or in-depth knowledge of pathophysiological states as it is based on cognitive structures that describe the features of prototypical or even actual patients. These cognitive structures, referred to as "illness scripts," contain relatively little knowledge about pathophysiological causes of symptoms and complaints but a wealth of clinically relevant information about disease, its consequences, and the context under which illness develops. By contrast, intermediate-level students without clinical experience typically use pathophysiological, causal models of disease when solving problems. The authors review evidence supporting the theory and discuss its implications for the understanding of five phenomena extensively documented in the clinical-reasoning literature: (1) content specificity in diagnostic performance; (2) typical differences in data-gathering techniques between medical students and physicians; (3) difficulties involved in setting standards; (4) a decline in performance on certain measures of clinical reasoning with increasing expertise; and (5) a paradoxical association between errors and longer response times in visual diagnosis.
What are the factors responsible for skilled typing performance, and do they change with the age of the typist? These questions were addressed in two studies by examining time and accuracy of keystrokes in a variety of typinglike activities among typists ranging in speed from 17 to 104 net words per minute and ranging in age from 19 to 72 years old. Typing skill was related to the temporal consistency of making the same keystroke, the efficiency of overlapping successive keystrokes, the speed of alternate-hand tapping, and the number of characters of to-be-typed text required to maintain a normal rate of typing. Older typists were slower in tapping rate and in choice reaction time but were not slower in speed of typing, apparently because they were more sensitive to characters farther in advance of the currently typed character than young typists.
The traditional system of clinical education in emergency medicine relies on practicing diagnostic, therapeutic, and procedural skills on live patients. The ethical, financial, and practical weaknesses of this system are well recognized, but the alternatives that have been explored to date have shown even greater flaws. However, ongoing progress in the area of virtual reality and computer-enhanced simulation is now providing educational applications that show tremendous promise in overcoming most of the deficiencies associated with live-patient training. It will be important for academic emergency physicians to become more involved with this technology to ensure that our educational system benefits optimally.
Objectives:
To describe a training method with objective evaluation to enhance laparoscopic surgical skills, to provide training in laparoscopic suturing techniques, and to assess whether specific training exercises were helpful in the attainment of intracorporeal suturing skills.
Design:
Trainees (N=150) were asked to perform standardized drills with distinct mechanical features, and skill acquisition was determined by accuracy and timing. Trainees were tested for the ability to perform an intracorporeal laparoscopic suture before and after analogous skill training with the drills.
Setting:
The training courses were held in teaching and nonteaching hospitals.
Participants:
Board-certified or board-eligible surgeons.
Main Outcome Measures:
Supervision by trained instructors and documentation of the time required to perform standardized drills.
Results:
The trainees showed steady improvement in skill acquisition during 10 trials (P<.001). Significant (P<.001) improvement was noted for the performance of suturing after compared with before the drills.
Conclusion:
Three standardized laparoscopic drills have been tested in 150 trainees and demonstrate the incremental acquisition of skills that correlate with improved performance in a challenging and complex laparoscopic skill, intracorporeal suturing.Arch Surg. 1997;132:200-204
Context.
—Medical educators have had a growing sense that proficiency in physical diagnostic skills is waning, but few data have examined the question critically.Objective, Design, and Setting.
—To compare the cardiac auscultatory proficiency of medical students and physicians in training. A multicenter cross-sectional assessment of students and house staff. A total of 8 internal medicine and 23 family practice programs of the mid-Atlantic area.Participants.
—A total of 453 physicians in training and 88 medical students.Interventions.
—All participants listened to 12 cardiac events directly recorded from patients, which they identified by completing a multiple-choice questionnaire.Main Outcome Measures.
—Scores were expressed as the percentage of participants, for year and type of training, who correctly identified each event. Cumulative scores were expressed as the total number of events correctly recognized. An adjusted score was calculated whenever participants selected not only the correct finding but also findings that are acoustically similar and yet absent.Results.
—Trainees' cumulative scores ranged between 0 and 7 for both internal medicine and family practice residents (median, 2.5 and 2.0, respectively). Internal medicine residents had the highest cumulative adjusted scores for the 6 extra sounds and for all 12 cardiac events tested (P=.01 and.02, respectively). On average, internal medicine and family practice residents recognized 20% of all cardiac events; the number of correct identifications improved little with year of training and was not significantly higher than the number identified by medical students.Conclusions.
—Both Both internal medicine and family practice trainees had a disturbingly low identification rate for 12 important and commonly encountered cardiac events. This study suggests a need to improve the teaching and assessment of cardiac auscultation during generalists' training, particularly with the advent of managed care and its search for more cost-effective uses of technology.
Background
Laparoscopic surgery adapts poorly to apprenticeship models for general surgical training. Standardized skill acquisition and validation programs, targeted performance goals, and a supervised, enforced, skill-based curriculum that readily can be shared between trainee and instructor must replace the observation and incremental skill-acquisition model used in an open surgical environment. The Yale Laparoscopic Skills and Suturing Program was used to develop a data bank for objective evaluation of dexterity and suturing skills for laparoscopic surgical training. The current study compares trainee and senior surgeon performance in this standardized training program.Objective
To compare objectively evaluated laparoscopic surgical skills and suturing capability of senior surgeons and of residents after they have completed the same standardized training regimen.Methods
Two hundred ninety-one trained surgeons performed 8730 standardized laparoscopic dexterity drills and 2910 intracorporeal suturing exercises in the Yale Laparoscopic Skills and Suturing Program. Their performance was supervised by an instructor who recorded performance and timing of the tasks in a 2
12
-day program. Ninety-nine residents performed the same drills and exercises the same number of times and followed the same technique for intracorporeal suturing. Percentile graphs were prepared for each type of drill and suturing exercise to allow comparison of levels of achievement among different training groups.Results
The performance of the residents was the same as that of trained surgeons for the rope pass drill and the suturing exercise. Residents in comparison with trained surgeons performed the triangle transfer drill faster and the new cup drop drill and old cup drop drill more slowly. There was no significant difference in performance between male and female residents.Conclusion
Basic skills relevant to laparoscopic performance can be acquired with a high level of competence in a brief course unrelated to prior surgical experience, sex, or age.
• To examine the development of expertise in dermatology, accuracy of diagnosis and response times of subjects at five levels of expertise were assessed. A total of 100 slides, 2 typical and 3 atypical slides from each of 20 common skin disorders, were presented to six subjects at each of the following levels: second-year preclinical medical students, final year medical students, residents in family medicine, general practitioners, and dermatologists. Accuracy of diagnosis rose from 21% for medical students to 87% for dermatologists. Correct diagnosis was associated with a decrease in response time with expertise, whereas errors were associated with a dramatic increase in response time, and was slower than correct response times at all levels, suggesting that errors do not result predominantly from carelessness or speed. Typical slides accounted for a constant proportion of diagnostic errors at all higher levels of expertise, and experts continued to make a significant proportion of errors on slides shown to be relatively easy for residents. The results are shown to be at variance with any model that equates expertise with the mastery of complex rules, but they are consistent with models of expertise that propose that expertise is equated with a rapid "patternrecognition" process, and errors result from unintended confusion with previous similar examples.
(Arch Dermatol. 1989;125:1063-1068)
Objective: To demonstrate that virtual reality (VR) training transfers technical skills to the operating room (OR) environment. Summary Background Data: The use of VR surgical simulation to train skills and reduce error risk in the OR has never been demonstrated in a prospective, randomized, blinded study. Methods: Sixteen surgical residents (PGY 1–4) had baseline psychomotor abilities assessed, then were randomized to either VR training (MIST VR simulator diathermy task) until expert criterion levels established by experienced laparoscopists were achieved (n = 8), or control non-VR-trained (n = 8). All subjects performed laparoscopic cholecystectomy with an attending surgeon blinded to training status. Videotapes of gallbladder dissection were reviewed independently by two investigators blinded to subject identity and training, and scored for eight predefined errors for each procedure minute (interrater reliability of error assessment r > 0.80). Results: No differences in baseline assessments were found between groups. Gallbladder dissection was 29% faster for VR-trained residents. Non-VR-trained residents were nine times more likely to transiently fail to make progress (P < .007, Mann-Whitney test) and five times more likely to injure the gallbladder or burn nontarget tissue (chi-square = 4.27, P < .04). Mean errors were six times less likely to occur in the VR-trained group (1.19 vs. 7.38 errors per case;P < .008, Mann-Whitney test). Conclusions: The use of VR surgical simulation to reach specific target criteria significantly improved the OR performance of residents during laparoscopic cholecystectomy. This validation of transfer of training skills from VR to OR sets the stage for more sophisticated uses of VR in assessment, training, error reduction, and certification of surgeons.
The present study was conducted to investigate qualitative changes that occur in the structure of knowledge in acquiring medical expertise. Therefore, the representation of pathophysiological knowledge was compared in subjects at four different levels of expertise. Subjects studied four clinical cases under three different time constraints, and provided a diagnosis and a pathophysiological explanation for the signs and symptoms in each case. Both diagnostic accuracy and quality of explanations increased with level of expertise. The explanations of experts, however, were less elaborate and less detailed than those of students. Constraining processing time affected the quality of explanations of advanced students, but not that of experts; conversely, the elaborateness and level of detail of explanations was affected in experts but not in students. The findings are explained by a network model integrating the two-world hypothesis in which biomedical and clinical knowledge are organised as two worlds apart (Patel, Evans, & Groen, 1989a, b) and the hypothesis of knowledge encapsulation in which biomedical knowledge becomes encapsulated into clinical knowledge (Schmidt & Boshuizen, 1992).
Conducted a meta-analysis of flight simulation research to identify important characteristics associated with the effectiveness of simulator training. Some 247 articles, research reports, and technical reports were located, from which 26 experiments were identified as having sufficient information for statistical meta-analysis. The major finding was that the use of simulators combined with aircraft training consistently produced improvements in training for jets compared to aircraft training only. Use of motion cuing added little to the training environments for jets. The average effectiveness of performance-paced training was greater than that for lock-step training. In general, training outcomes appear to be influenced considerably by the type of task and the amount and type of training given. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
The military is focusing a great deal of effort on developing virtual world technologies that will allow training combat skills in flight simulators. Considerably less attention is being directed toward documenting the effectiveness of such training. In this article, we review Air Force and Navy efforts to evaluate the effectiveness of training the combat skills necessary for attack and fighter aircraft in flight simulators. The majority of these efforts indicate that simulation can be a valuable complement to the aircraft. Unfortunately, this conclusion is based primarily on opinion data from experienced aviators. There are very few transfer of training experiments, and those experiments have examined only a limited set of combat tasks. We also describe the typical paradigms used to conduct training evaluations and outline a multistep evaluation program for determining training effectiveness.
Background
High-volume hospitals have been shown to have superior outcomes after carotid endarterectomy (CEA), but the contribution of surgeon volume and specialty practice to CEA outcomes in a national sample is unknown.
In this study, first‐year residents in family medicine (FM), first‐ and second‐year residents in internal medicine, and experienced academic nephrologists were confronted with a series of eight complex nephrology problems, represented by a brief written history and a standard array of laboratory data. Subjects were asked to solve the problem while “thinking aloud.”; Results showed a large gradient in diagnostic ability over the three cohorts, ranging from a mean accuracy of 25% for FM residents to 91% for nephrologists. Increased experience was associated with increased clustering of individual data into meaningful relations and more extensive use of causal explanations but no difference in use of forward or backward reasoning. These results are at variance with an extensive literature showing (a) no or little difference in outcome measures of clinical competence related to postgraduate education but (b) greater use of forward reasoning and less use of causal biomedical explanations, associated with increased expertise. An explanation in terms of Schmidt and Norman's stage theory is proposed.
This article is concerned with the role of so-called encapsulated knowledge and biomedical knowledge in the process of diagnosing clinical cases within and outside the medical specialist's domain of expertise. Based on the theory of knowledge encapsulation, we predicted that subexperts (i.e., medical specialists diagnosing a clinical case outside their specialty) could not diagnose a clinical case in an encapsulated mode, and therefore they would relapse into an elaborate biomedical processing approach to understand the described signs and symptoms. Cardiologists (the experts) and Neurologists (the subexperts) were instructed to study 2 clinical case descriptions for a period of 3 min per case. After each case they were asked to provide a diagnosis, write down everything they remembered of the case, and finally to explain the signs and symptoms displayed in the case. The results show that cardiologists achieved a higher diagnostic accuracy than did neurologists. Furthermore, the cardiologists' recall and pathophysiological explanations contained more high-level inferences (i.e., encapsulations) than those of neurologists. These outcomes are in line with the predictions made on the basis of the theory of knowledge encapsulation.
This article describes a three-part empirical approach to understanding the development of expertise within the UNIX' operating system. We studied UNIX users with varying levels of expertise. The first part of our research attempted to ascertain the nature of their conceptualizations of the UNIX system. The second part measured users' performance in tasks requiring them to comprehend and produce UNIX commands. The third part was a longitudinal rather than cross-sectional analysis of the emergence of expertise. The conceptualization data suggest important differences in the models of UNIX structure formed by each group. Experts best represent the higher levels of the UNIX system; novices more fully represent the lower, more concrete levels of the system, including specific commands. UNIX users also differ markedly in performance, according to their history of use with the operating system. Only experts could successfully produce composite commands that required use of the distinctive features of UNIX (e.g., pipes and other redirection symbols), even though the intermediates and novices evidenced the component knowledge required for composite commands. This finding is somewhat surprising, inasmuch as these are fundamental design features of UNIX, and these features are taught in elementary classes. These data suggest, however, that these features can be used reliably only after extensive experience. The longitudinal data suggest that most subjects increased in expertise. However, expertise can decrease as a function of time, depending on system use. Those subjects who increased in expertise acquired the ability to produce the simple commands and represent the basic modules before they acquired knowledge of complex commands and advanced utilities. The nature of expertise is considered with respect to both system design and user characteristics, including users' conceptual models of system structure.
Nine hundred and thirty-three physicians have been tested to evaluate their ability to make cardiac diagnoses by auscultation alone. Fifteen "unknowns," recorded on tape and played back through individual stethophones, with simultaneous presentation of the visual pattern of the sound on the face of an oscilloscope, were used for the test. The "unknowns" were all classic examples of common normal and abnormal auscultatory phenomena and had been pre-tested to assure fidelity of reproduction and the ability of physicians with adequate training in auscultation to identify the examples readily. The highest scores were achieved by those physicians who had been certified in the subspecialty of cardiovascular disease while the lowest scores were made by physicians without specialized training who had been in practice for more than 20 years.
Interpreting a scientific concept, that is, identifying or generating it properly in any particular instance, is a complex cognitive task. We analyze the underlying knowledge required to achieve such concept interpretation accurately and efficiently. This analysis is used to examine detailed observations of expert scientists and novice students interpreting the physics concept of acceleration. Most experts interpret the concept well in expected ways; however, even some experienced scientists exhibit marked deficiencies in concept interpretation. Novice students, even after using a scientific concept for some months, interpret it incorrectly in many cases. Their poor performance can be traced to concept knowledge that is largely incoherent, consisting of disconnected knowledge elements leading to frequent paradoxes. These knowledge elements are often flawed because of deficient applicability conditions or lack of discriminations. Furthermore, students' definitional or other general knowledge often cannot be properly applied, even if correctly stated. By directly addressing such deficiencies, instruction can substantially improve students' ability to interpret a scientific concept.
Recent research in many different domains of expertise has shown that the large differences in performance between experts and novices are frequently reproducible under standardized conditions and can often be captured with representative tasks in the laboratory. Furthermore, these differences in performance are predominantly mediated by complex skills acquired over a decade, as a result of high daily levels of activities which are specially designed'to improve performance (deliberate practice). The effects of extended deliberate practice are remarkably far‐reaching and include physiological adaptations and qualitative changes in performance mediated by acquired cognitive skills. Most importantly, expert performers have acquired mental representations that allow them to plan and reason about potential courses of action and these representations also allow experts to monitor their performance, thus providing critical feedback for continued complex learning. The study of elite performance also reveals how acquired representation and skills provide the necessary tools for the ultimate eminent achievement, namely the generation of creative innovations to the domain. This paper is a revised and updated version of my keynote address at the international conference on Creativity & culture: Talent development in the arts and sciences sponsored by European Council on High Ability, Vienna, Austria, 19-22 October (22 October).
Reviews the origins, findings, and influence of the monograph
Medical problem solving:
An analysis of clinical reasoning by A. S. Elstein et al (1978). Methodological problems and scholarly issues in the field of cognition are discussed, including (1) sampling cases and Ss, (2) the definition of medical expertise, (3) the role of verbal report in analyzing thinking, (4) the level of clinical realism needed in research, and (5) the relation of information-processing approaches to more quantitative approaches such as behavioral decision theory and social judgment theory. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Outlines a theory that assumes the development of expertise in medicine is based on cognitive structures that describe the features of prototypical or actual patients and that are referred to as "illness scripts." Evidence is reviewed supporting the theory. Five phenomena extensively documented in the clinical-reasoning literature are discussed: (1) content specificity in diagnostic performance, (2) typical differences in data-gathering techniques between medical students and physicians, (3) difficulties involved in setting standards, (4) a decline in performance on certain measures of clinical reasoning with increasing expertise, and (5) a paradoxical association between errors and longer response times in visual diagnosis. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Describes a series of experiments conducted on the racquet sports of badminton and squash to determine the location of the advance cues that provide critical anticipatory information and to document any expert–novice differences in anticipatory cue usage. Data suggest movement of the arm and racquet and outward flight of the struck ball (or shuttle) as the source of the critical cues for racquet sports, and a close match was found between the visual search sequence and the proximal-to-distal kinematic development of the opponent's stroke. Expert racquet sport players differed from novices in terms of their ability to use the earlier occurring, more proximal arm cues as a basis for predicting resultant stroke speed and direction, but these differences in information pick-up were not matched by differences in visual search strategy. (French, Spanish, German & Italian abstracts) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This is the fourth in a series of five articlesThis article reviews our current understanding of the cognitive processes involved in diagnostic reasoning in clinical medicine. It describes and analyses the psychological processes employed in identifying and solving diagnostic problems and reviews errors and pitfalls in diagnostic reasoning in the light of two particularly influential approaches: problem solving1, 2, 3 and decision making.4, 5, 6, 7, 8 Problem solving research was initially aimed at describing reasoning by expert physicians, to improve instruction of medical students and house officers. Psychological decision research has been influenced from the start by statistical models of reasoning under uncertainty, and has concentrated on identifying departures from these standards.
Summary points
Problem solving and decision making are two paradigms for psychological research on clinical reasoning, each with its own assumptions and methods
The choice of strategy for diagnostic problem solving depends on the perceived difficulty of the case and on knowledge of content as well as strategy
Final conclusions should depend both on prior belief and strength of the evidence
Conclusions reached by Bayes's theorem and clinical intuition may conflict
Because of cognitive limitations, systematic biases and errors result from employing simpler rather than more complex cognitive strategies
Evidence based medicine applies decision theory to clinical diagnosis
Problem solving
Diagnosis as selecting a hypothesis
The earliest psychological formulation viewed diagnostic reasoning as a process of testing hypotheses. Solutions to difficult diagnostic problems were found by generating a limited number of hypotheses early in the diagnostic process and using them to guide subsequent collection of data.1 Each hypothesis can be used to predict what additional findings ought to be present if it were true, and the diagnostic process is a guided search for these findings. Experienced physicians form hypotheses and their diagnostic plan rapidly, and the …
To make genuine progress toward explicating the relation
between innate talent and high levels of ability, we need to consider
the differences in structure between most everyday abilities and
expert performance. Only in expert performance is it possible to
show consistently that individuals can acquire skills to circumvent
and modify basic characteristics (talent).
This paper examines the use of different types of knowledge at different levels of expertise in the domain of electrocardiogram (ECG) interpretation. Analyses of constructive interaction protocols from expert, novice and intermediate subjects working in same-skill pairs on six ECG traces indicated that: novice and intermediate pairs produced proportionately more trace characterizing statements than the other groups; expert pairs produced proportionately more clinical hypothesis statements and proportionately fewer but more complex biomedical inference statements than the other groups. © 1997 John Wiley & Sons, Ltd.
To examine the effect of clinical history on the electrocardiogram (ECG) interpretation skills of physicians with different
levels of expertise, we randomly allocated to an ECG test package 30 final-year medical students, 15 second-year internal
medicine residents, and 15 university cardiologists at university-affiliated teaching hospitals. All participants interpreted
the same set of 10 ECGs. Each ECG was accompanied by a brief clinical history suggestive of the correct ECG diagnosis, or
the most plausible alternative diagnosis, or no history. Provision of a correct history improved accuracy by 4% to 12% compared
with no history, depending on level of training. Conversely, a misleading history compared with no history reduced accuracy
by 5% for cardiologists, 25% for residents, and 19% for students. Clinical history also affected the paticipants’ frequencies
of listing ECG features consistent with the correct diagnosis and features consistent with the alternative diagnosis (allp values <.05). For physicians at all levels of expertise, clinical history has an influence on ECG diagnostic accuracy, both
improving accuracy when the history suggests the correct diagnosis, and reducing accuracy when the history suggests an alternative
diagnosis.
(from the chapter) summarize some of the findings on expertise in chess / the theme being stressed is the opportunity for trading off knowledge and search to reach a single goal: skilled play / first, the extensive search capabilities of nonhuman chess players, computer chess programs, will be examined / psychological investigations of human chess skill will then be reviewed to contrast the ways in which the two "species" achieve expertise the knowledge base that humans have developed about chess will be assessed, using encyclopedic sources concerning the three phases of chess: the opening, the middle game, and the end game / look at whether knowledge accumulation and training in chess have meant better play, both over time and across chess federations / the extent to which an understanding of chess skill can be of assistance in understanding other types of human skill will be briefly discussed (PsycINFO Database Record (c) 2000 APA, all rights reserved)
Two approaches to the study of diagnostic thinking are compared, one mainly propositional, namely that of Patel and Groen (1986), the other mainly semantic, that of Lemieux and Bordage (1986). Patel and Groen analyzed the linear dimension of cardiologists' discourses while solving a case of acute bacterial endocarditis, that is, the before and after propositional rules. A secondary analysis of two of their pothophysiological protocols is done using structural semantic techniques from Lemieux and Bordage where the vertical dimension of the discourses is analyzed, that is, the levels of meaning or semantic axes. Contrary to Patel and Groen's position, making an accurate diagnosis is not explained in terms of pure forward reasoning through networks of causal rules, but by means of networks of semantic qualities abstracted from the symptoms and signs. The semantic qualities operate in the clinician's mind in terms of binary oppositions (e.g., sudden-gradual, unilateral-bilateral) whereby each pair of properties constitutes a semantic axis (e.g., sudden-gradual). The successful diagnosticians are those who use the most diversified and pertinent set of semantic axes and, therefore, have a deeper representation of the problem.
The techniques of propositionol analysis are used to examine the protocols of seven cardiologists in a task involving the diagnosis of a case of acute bacterial endocarditis and an explanation of its underlying pathophysiology. It is shown that the explanations of physicians making an accurate diagnosis can be accounted for in terms of a model consisting of pure forward reasoning through a network of causal rules, actuated by relevant propositions embedded in the stimulus text. These rules appear to derive from the physician's underlying knowledge base rather than any information in the text itself. In contrast, subjects with inacurate diagnoses tend to make use of a mixture of forward and backward reasoning, beginning with a high level hypothesis and proceeding in a top-down fashion to the propositions embedded in stimulus text, or to the generation of irrelevant rules.
To account for the large demands on working memory during text comprehension and expert performance, the traditional models of working memory involving temporary storage must be extended to include working memory based on storage in long-term memory. In the proposed theoretical framework cognitive processes are viewed as a sequence of stable states representing end products of processing. In skilled activities, acquired memory skills allow these end products to be stored in long-term memory and kept directly accessible by means of retrieval cues in short-term memory, as proposed by skilled memory theory. These theoretical claims are supported by a review of evidence on memory in text comprehension and expert performance in such domains as mental calculation, medical diagnosis, and chess.
To examine the development of expertise in dermatology, accuracy of diagnosis and response times of subjects at five levels of expertise were assessed. A total of 100 slides, 2 typical and 3 atypical slides from each of 20 common skin disorders, were presented to six subjects at each of the following levels: second-year preclinical medical students, final year medical students, residents in family medicine, general practitioners, and dermatologists. Accuracy of diagnosis rose from 21% for medical students to 87% for dermatologists. Correct diagnosis was associated with a decrease in response time with expertise, whereas errors were associated with a dramatic increase in response time, and was slower than correct response times at all levels, suggesting that errors do not result predominantly from carelessness or speed. Typical slides accounted for a constant proportion of diagnostic errors at all higher levels of expertise, and experts continued to make a significant proportion of errors on slides shown to be relatively easy for residents. The results are shown to be at variance with any model that equates expertise with the mastery of complex rules, but they are consistent with models of expertise that propose that expertise is equated with a rapid "pattern-recognition" process, and errors result from unintended confusion with previous similar examples.
The purpose of this study is to identify the age of peak performance in a broad range of athletic events incorporating multiple,
diverse biological systems, learned skills, and motivation. Although many researchers have noted that the absolute levels
of peak performance among superathletes have improved dramatically in the last 100 years, to date no one has answered the
question of stability of peak performance age over this time period. Analyses of Olympic track and field and swimming data
show that the age at which peak performance is achieved has remained remarkably consistent. For both men and women, the age
of peak performance increases with the length of the foot race, and women generally achieve peak performance at younger ages.
The pattern of increased age with increasing distance is reversed for female swimmers, where younger ages are associated with
increasing distance. For most categories of performance in baseball, the peak age of performance is equivalent to that of
a long distance runner, about 28 years of age, while top tennis players reach their highest levels of performance at age 24.
Golfers, in comparison, peak at about 31 years of age, although recent data suggest movement toward younger ages. A task analysis
of each event is carried out, and the relative roles of biology and learning are discussed as determinants of peak performance.
The evolution of clinical reasoning in medical students was studied. A cross-sectional sample consisted of randomly-selected medical students from three classes. Additionally, twenty-two students were observed at yearly intervals from the preclerkship period to the first post-graduate year. Subjects were observed in a clinical examination of a simulated patient, and their thought processes were abstracted from a ‘stimulated recall’ of the videotaped encounter.
The data were transcribed and coded for computer analysis, yielding several variables characterizing the clinical reasoning process, and four measures of outcome of the encounter. Analysis of variance of differences between students at various educational levels and a doctor criterion group indicated that the majority of the process variables were unrelated to educational level. By contrast, diagnostic and management outcomes were positively related to education. The single process variable which was related to both educational level and outcome was an ‘hypothesis aggregate score’, a measure of the content of the student's diagnostic hypotheses.
The results of the study indicate that the problem-solving or clinical reasoning process remains relatively constant from medical school entry to practice. This observation has important implications for clinical teaching and evaluation.
Data derived from high-fidelity simulation studies of medical diagnostic reasoning are reanalyzed and critiqued. Results from the reanalyses do not support the earlier findings. The reanalyses also raise questions about the validity of a psychological model of diagnostic inquiry that formed the foundation of the high-fidelity simulation research. Suggestions regarding alternate methods for conducting research on diagnostic problem-solving are offered.
In 1969 the American Board of Family Practice (ABFP) became the 19th medical specialty board and the first since the inception of medical specialty certification to mandate recertification. As of July 1993, 16 other boards have adopted time-limited certification, but only two have reached the first recertification of their diplomates. As recertification approaches for the 14 boards, each will be faced with decisions concerning process, examination content and scope, and standards for passing. The physicians who will be facing mandatory recertification must be adequately prepared or accept the consequences of losing their certification.
This study examined the performances of six cohorts of family physicians--three cohorts of 711 practice-qualified physicians certified in 1971, 1972, and 1973, and three cohorts of 1,233 residency-trained physicians certified in 1977, 1978, and 1979--who were successfully recertified on successive six-year cycles from 1977 through 1991. Analyses of variance, multiple regression analysis, and Pearson correlation coefficients were used to investigate the relationships among the composite scores on the various certification and recertification examinations and among examination composite scores and demographic variables.
There were significant (p < .01) declines in performance on each recertification examination. The residency-trained physicians had higher examination scores than did the practice-qualified physicians. Multiple regression analysis showed the last recertification score to be the strongest predictor of the next recertification score. The combination of previous scores and demographic variables resulted in the ability to predict between 63% and 74% of the variance in the most current recertification composite score.
The results raise questions for further investigation, and such investigation may affect specialty boards' design of and/or examinees' test-taking strategies on future recertification examinations. For example, the decline in examination performance from certification through successive recertifications may result from factors related to the practice of medicine. It is possible that as the practice life of a family physician evolves, the focus of the practice becomes narrower, and this narrowed focus results in a decline in performance on an examination, half of which covers the breadth of the specialty. Thus, the medical specialties addressing mandatory recertification may wish to give thorough consideration to the focus of the examination--scope of specialty or scope of the practice, or some combination of both--as well as the implications of the standard-setting process used for recertification.