Anders Ericsson, a psychologist and eminent scholar on the topic of expertise, has written extensively about how deliberate practice affects the daily work of medical professionals. Essentially, constant practice, coupled with a strong desire to improve, leads to expert-level performance. Physicians are not born experts — they develop expertise through persistence and unrelenting self-assessment. In the context of medical education, how might you apply Ericsson’s ideas to your own professional growth?
Deliberate Practice Requires Flexibility
It’s important to understand that the practice of medicine is exactly that — practice. Practitioners are always refining their craft and trying to become the best they can be, ultimately for their patients.
Being a clinician is hard, but it is incredibly rewarding. Caring for patients is truly a privilege, and with that privilege comes the responsibility of being at the top of your game when providing that care. That means knowing what you need to know to provide high-quality care, listening intently, and understanding the power of shared decision making with patients. It also means adjusting your practice when medicine evolves. I remember the days when beta-blockers were contraindicated for patients with heart failure and a low ejection fraction and when sublingual nifedipine was used to lower blood pressure. My, how the medical field changes!
I am reminded of some of my own mentors, who were incredibly methodical in how they took a patient’s history and conducted a physical examination. Once, on teaching rounds, we were evaluating a patient with an abnormal heart valve. I wanted to go right to using a stethoscope, but the attending physician advised the team to first look (inspection) and feel (palpation) before listening (auscultation). This was a pivotal moment in my appreciation of the importance of deliberate practice. Mentors who are keenly aware of how their juniors, like me at the time, consume information and use it to help their own patients are effective in teaching younger physicians to become experts in their own right.
Deliberate Practice Is a Lifelong Haul
In comparing expert musicians with non-experts, Ericsson found that the experts practiced more by themselves, focusing on improving specific components of their musical performance. The number of hours of practice to achieve expert status was about 10,000 hours.
How does this play out in daily work as a clinician? Well, I think of a common remark by medical residents when they are learning to examine the retina: “I’m not very good with an ophthalmoscope.” While this may be true for many residents, the best way to get better is to do it often and keep assessing your progress. By examining the retina of every patient with hypertension you encounter (there are lots out there) and learning from each one, you gradually improve. One day, you will evaluate a patient with chronic hypertension and that patient will exhibit arteriovenous (AV) nicking. If you’ve become comfortable using an ophthalmoscope and you know what to look for, you’ll be more likely to find it.
I think I’m skilled at using an ophthalmoscope, not because it came to me instantly but because I practiced using one over and over and over again. When I saw AV nicking in practice, I made sure to point it out to others, such as residents in an outpatient teaching clinic. I will continue to do this maneuver when I feel it is indicated and best for patient care, and I will do my best to mentor others in how to use it, even though I am still not perfect at it.
Tips for the Budding Expert
Whether I’m using an ophthalmoscope or taking a patient’s history, here are five maxims I try to live by in pursuing expertise in the deliberate practice of medicine:
- Always remember to perform the basics, such as a good history and physical examination.
- Commit to practicing again and again.
- Realize that certain tasks, such as interviewing a patient, are so complex that each time you do them, you’ll learn something about how to do them better next time.
- Make use of goal-directed training and early feedback from people who are already experts.
- Always pause to assess your progress, even though it takes time.
Medicine is a fascinating field that offers ample opportunity to learn every day and to develop the expertise that Ericsson’s work elucidates so impressively. As practicing clinicians, we can always strive to become better through deliberate practice, with the ultimate goal of helping our patients.