Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains

Communicating with cancer patients: what areas do physician assistants find most challenging?

Physician assistants (PAs) and other midlevel practitioners have been taking on increasing clinical roles in oncology settings. Little is known about the communication needs and skills of oncology PAs. PAs working in oncology (n = 301) completed an online survey that included questions about their perceived skill and difficulty on several key communication tasks. Overall, PAs rated these communication tasks as "somewhat" to "moderately" difficult and their skill level in these areas as "average" to "good." Areas of most perceived difficulty were intervening with angry patients or those in denial and breaking bad news. Highest perceived skills were in communicating with patients from cultures and religions different than your own and telling patient he/she has cancer or disease has progressed, and the lowest perceived skills were in discussing do not resuscitate orders. There are areas in which enhancement of communication skills may be needed, and educational opportunities should be developed for PAs working in oncology.

Use of simulator-based medical procedural curriculum: the learner's perspectives

BACKGROUND

Simulation is increasingly used for teaching medical procedures. The goal of this study was to assess learner preferences for how simulators should be used in a procedural curriculum.

METHODS

A 26-item survey was constructed to assess the optimal use of simulators for the teaching of medical procedures in an internal medicine residency curriculum. Survey domains were generated independently by two investigators and validated by an expert panel (n = 7). Final survey items were revised based on pilot survey and distributed to 128 internal medicine residents.

RESULTS

Of the 128 residents surveyed, 106 (83%) responded. Most responders felt that simulators should be used to learn technical skills (94%), refine technical skills (84%), and acquire procedural teaching skills (87%). Respondents felt that procedures most effectively taught by simulators include: central venous catheterization, thoracentesis, intubation, lumbar puncture, and paracentesis. The majority of learners felt that teaching should be done early in residency (97%). With regards to course format, 62% of respondents felt that no more than 3-4 learners per simulator and an instructor to learner ratio of 1:3-4 would be acceptable.The majority felt that the role of instructors should include demonstration of technique (92%), observe learner techniques (92%), teach evidence behind procedural steps (84%) and provide feedback (89%). Commonly cited barriers to procedural teaching were limitations in time, number of instructors and simulators, and lack of realism of some simulators.

CONCLUSIONS

Our results suggest that residents value simulator-based procedural teaching in the form of small-group sessions. Simulators should be an integral part of medical procedural education.

A prospective randomized trial of content expertise versus process expertise in small group teaching

BACKGROUND

Effective teaching requires an understanding of both what (content knowledge) and how (process knowledge) to teach. While previous studies involving medical students have compared preceptors with greater or lesser content knowledge, it is unclear whether process expertise can compensate for deficient content expertise. Therefore, the objective of our study was to compare the effect of preceptors with process expertise to those with content expertise on medical students' learning outcomes in a structured small group environment.

METHODS

One hundred and fifty-one first year medical students were randomized to 11 groups for the small group component of the Cardiovascular-Respiratory course at the University of Calgary. Each group was then block randomized to one of three streams for the entire course: tutoring exclusively by physicians with content expertise (n = 5), tutoring exclusively by physicians with process expertise (n = 3), and tutoring by content experts for 11 sessions and process experts for 10 sessions (n = 3). After each of the 21 small group sessions, students evaluated their preceptors' teaching with a standardized instrument. Students' knowledge acquisition was assessed by an end-of-course multiple choice (EOC-MCQ) examination.

RESULTS

Students rated the process experts significantly higher on each of the instrument's 15 items, including the overall rating. Students' mean score (±SD) on the EOC-MCQ exam was 76.1% (8.1) for groups taught by content experts, 78.2% (7.8) for the combination group and 79.5% (9.2) for process expert groups (p = 0.11). By linear regression student performance was higher if they had been taught by process experts (regression coefficient 2.7 [0.1, 5.4], p < .05), but not content experts (p = .09).

CONCLUSIONS

When preceptors are physicians, content expertise is not a prerequisite to teach first year medical students within a structured small group environment; preceptors with process expertise result in at least equivalent, if not superior, student outcomes in this setting.

Computerized virtual patients in health professions education: a systematic review and meta-analysis

PURPOSE

Educators increasingly use virtual patients (computerized clinical case simulations) in health professions training. The authors summarize the effect of virtual patients compared with no intervention and alternate instructional methods, and elucidate features of effective virtual patient design.

METHOD

The authors searched MEDLINE, EMBASE, CINAHL, ERIC, PsychINFO, and Scopus through February 2009 for studies describing virtual patients for practicing and student physicians, nurses, and other health professionals. Reviewers, working in duplicate, abstracted information on instructional design and outcomes. Effect sizes were pooled using a random-effects model.

RESULTS

Four qualitative, 18 no-intervention controlled, 21 noncomputer instruction-comparative, and 11 computer-assisted instruction-comparative studies were found. Heterogeneity was large (I²>50%) in most analyses. Compared with no intervention, the pooled effect size (95% confidence interval; number of studies) was 0.94 (0.69 to 1.19; N=11) for knowledge outcomes, 0.80 (0.52 to 1.08; N=5) for clinical reasoning, and 0.90 (0.61 to 1.19; N=9) for other skills. Compared with noncomputer instruction, pooled effect size (positive numbers favoring virtual patients) was -0.17 (-0.57 to 0.24; N=8) for satisfaction, 0.06 (-0.14 to 0.25; N=5) for knowledge, -0.004 (-0.30 to 0.29; N=10) for reasoning, and 0.10 (-0.21 to 0.42; N=11) for other skills. Comparisons of different virtual patient designs suggest that repetition until demonstration of mastery, advance organizers, enhanced feedback, and explicitly contrasting cases can improve learning outcomes.

CONCLUSIONS

Virtual patients are associated with large positive effects compared with no intervention. Effects in comparison with noncomputer instruction are on average small. Further research clarifying how to effectively implement virtual patients is needed.

Long-term retention of central venous catheter insertion skills after simulation-based mastery learning

BACKGROUND

Simulation-based mastery learning (SBML) of central venous catheter (CVC) insertion improves trainee skill and patient care. How long skills are retained is unknown.

METHOD

This is a prospective cohort study. Subjects completed SBML and were required to meet or exceed a minimum passing score (MPS) for CVC insertion on a posttest. Skills were retested 6 and 12 months later and compared with posttest results to assess skill retention.

RESULTS

Forty-nine of 61 (80.3%) subjects completed follow-up testing. Although performance declined from posttest where 100% met the MPS for CVC insertion, 82.4% to 87.1% of trainees passed the exam and maintained their high performance up to one year after training.

CONCLUSIONS

Skills acquired from SBML were substantially retained during one year. Individual performance cannot be predicted, so programs should use periodic testing and refresher training to ensure competence.

Identifying and classifying problem areas in laparoscopic skills acquisition: can simulators help?

BACKGROUND

Independent learning with simulators might be improved if simulators could "diagnose the learner" by identifying common novice problems, thereby directing self-guided learning. Our goal was to determine if data collected by a virtual reality simulator could be used to predict the problem areas in novice trainees' laparoscopic performance.

METHOD

Fourteen expert laparoscopists were interviewed to identify common problem areas experienced by novices as they learn laparoscopy. Two expert laparoscopists rated 20 novices' simulator performances regarding the extent of each problem area.

RESULTS

Moderate interrater reliability and high "interproblem" correlations suggest that experts did not reliably distinguish between the five identified problem areas as expected.

CONCLUSIONS

The process by which expert teachers "diagnose" student difficulties did not reduce well to numeric assessments using linear independent scales in the simulated context. This finding raises challenges for our ability to identify such difficulties using the data collected by simulators.

Medical simulation in respiratory and critical care medicine

Simulation-based medical education has gained tremendous popularity over the past two decades. Driven by the patient safety movement, changes in the educational opportunities available to trainees and the rapidly evolving capabilities of computer technology, simulation-based medical education is now being used across the continuum of medical education. This review provides the reader with a perspective on simulation specific to respiratory and critical care medicine, including an overview of historical and modern simulation modalities and the current evidence supporting their use.

Residents' mental model of bag-mask ventilation

OBJECTIVES

Our objectives were to characterize resident knowledge of bag-mask ventilation (BMV) and to identify predictors of a well-developed mental model of BMV.

METHODS

A pilot survey of airway experts identified 6 steps considered essential in situations of difficult BMV. Subsequently, residents from pediatric, emergency medicine, and medicine-pediatric programs at a tertiary care hospital completed the same pediatric scenario-based item given to airway experts.

RESULTS

Of all surveys, 75% (n = 103) were completed. No resident identified all 6 maneuvers for difficult BMV. With decreasing frequency, the items identified were as follows: reposition patient/airway (82%), oral airway (61%), nasal airway (39%), jaw thrust (37%), 2-person technique (7%), and call for help (4%). Emergency medicine residents had a higher mean (SD) score than the medicine-pediatric and pediatric residents of a possible 6 (2.71 (1.26) vs 2.01 (1.07), P = 0.004) and were significantly more likely to identify certain maneuvers: oral airway (81% vs 52%, P = 0.006), nasal airway (57% vs 29%, P = 0.006), and 2-person technique (14% vs 3%, P = 0.042). Only 15% of all residents were able to identify 4 or more essential maneuvers. Higher level of training was associated with identifying the 2-person technique. In addition, residents who completed 1 month of pediatric or adult anesthesia were more likely to identify use of nasal airway, oral airway and 2-person technique, and to identify 4 or more maneuvers.

CONCLUSIONS

Emergency medicine residents identified more steps to optimize difficult BMV, although most residents exhibited a poorly developed mental model for difficult BMV compared with the consistent mental model of airway experts. Future research should investigate strategies for improving residents' mental model of BMV and its impact on patient care.

Evaluation of a transition to practice program for neurosurgery residents: creating a safe transition from resident to independent practitioner

BACKGROUND

In 2004, the Department of Neurosurgery at the University of Florida implemented a major curriculum innovation called the Transition to Practice program. This program was established to prepare residents to more safely transition to the role of independent practitioner.

METHODS

A qualitative and quantitative evaluation of the program was conducted after its fifth year using online surveys and interviews. Study participants included Transition to Practice graduates, faculty, and current residents.

RESULTS

Of the 26 respondents, 89% of faculty and all graduates were very satisfied with the program. Strengths identified included an independent yet mentored broad operative experience, the development of self-confidence, and a real sense of responsibility for patients. Medical billing and coding instruction and career mentoring were areas of the program that required additional attention.

CONCLUSION

Overall, this program is meeting the stated objectives and is well received by the graduates and faculty. Based on the results of this evaluation, curricular changes such as instructions in practice management and implementation of a career-mentoring program have occurred. The Transition to Practice program is a unique curricular response to change that other surgical specialties may find useful in addressing the current-day stresses on graduate medical education.

Creating and evaluating a data-driven curriculum for central venous catheter placement

BACKGROUND

Central venous catheter placement is a common procedure with a high incidence of error. Other fields requiring high reliability have used Failure Mode and Effects Analysis (FMEA) to prioritize quality and safety improvement efforts.

OBJECTIVE

To use FMEA in the development of a formal, standardized curriculum for central venous catheter training.

METHODS

We surveyed interns regarding their prior experience with central venous catheter placement. A multidisciplinary team used FMEA to identify high-priority failure modes and to develop online and hands-on training modules to decrease the frequency, diminish the severity, and improve the early detection of these failure modes. We required new interns to complete the modules and tracked their progress using multiple assessments.

RESULTS

Survey results showed new interns had little prior experience with central venous catheter placement. Using FMEA, we created a curriculum that focused on planning and execution skills and identified 3 priority topics: (1) retained guidewires, which led to training on handling catheters and guidewires; (2) improved needle access, which prompted the development of an ultrasound training module; and (3) catheter-associated bloodstream infections, which were addressed through training on maximum sterile barriers. Each module included assessments that measured progress toward recognition and avoidance of common failure modes. Since introducing this curriculum, the number of retained guidewires has fallen more than 4-fold. Rates of catheter-associated infections have not yet declined, and it will take time before ultrasound training will have a measurable effect.

CONCLUSION

The FMEA provided a process for curriculum development. Precise definitions of failure modes for retained guidewires facilitated development of a curriculum that contributed to a dramatic decrease in the frequency of this complication. Although infections and access complications have not yet declined, failure mode identification, curriculum development, and monitored implementation show substantial promise for improving patient safety during placement of central venous catheters.

The development of a comprehensive school-wide simulation-based procedural skills curriculum for medical students

OBJECTIVE

The purpose of this project was to assess the effectiveness of using the Delphi process to create a structured simulation-based procedural skills curriculum for all students at the Keck School of Medicine of the University of Southern California (KSOM).

METHODS

The Delphi process was used to develop a list of procedural skills that students are expected to perform competently prior to graduation. Once consensus of faculty was reached, a needs assessment was performed to poll graduating seniors' experience performing each skill. A comprehensive simulation-based curriculum was developed and implemented for all Year II students at KSOM. Student satisfaction with the curriculum was collected using a standardized end-of-session evaluation form and student self confidence was assessed using a retrospective pre- and post-self-efficacy rating for each skill.

RESULTS

The needs assessment clearly established the need for a more organized approach to teaching procedural skills at KSOM. Quantitative and qualitative data revealed that students responded favorably to the curriculum and appreciated the efforts put forth by KSOM. Student self-efficacy increased significantly for each skill.

CONCLUSIONS

The Delphi process was effective in reaching consensus among educational leaders at KSOM regarding which skills to include in the curriculum. Although there were a few minor challenges, we determined that it is feasible to develop and implement an explicit school-wide simulated-based procedural skills curriculum.

Recertification and continuing professional development: The way ahead

The arguments in favour of recertification have been made cogently. Doctors in the UK on the whole continue to enjoy the trust and respect of their patients and the general public, but the Shipman enquiry led by Dame Janet Smith questioned the validity of the existing system. Following a lengthy discussion, the Chief Medical Officer of England published his proposal for professional regulation: Trust, assurance and safety - the regulation of health professionals in the 21st century¹ was published in February 2007. This document laid out the principles of revalidation for all doctors practising in the United Kingdom. The purpose of revalidation is principally to ensure that doctors update their knowledge and skills, and that they are fit to practise. This mechanism of revalidation will ensure that health professionals will be able to demonstrate their continued fitness to practise by collecting supporting data. The medical revalidation has two components: relicensure and specialist recertification. From 16 November 2009 all doctors are expected to have a licence to practise to enable them to remain on the Medical Register, and this licence must be renewed every year. This process will be managed by the General Medical Council (GMC). Recertification will apply to all specialist doctors, including general practitioners, requiring them to demonstrate that they meet the standards that apply to their particular medical specialty. The Royal Colleges have been delegated to set these standards, and approved by the GMC. Recertification will take place every five years. Recertification will be underpinned by enhanced appraisal, multi source feedback, and a robust continuing professional development programme.

Simulation-based mastery learning improves cardiac auscultation skills in medical students

BACKGROUND

Cardiac auscultation is a core clinical skill. However, prior studies show that trainee skills are often deficient and that clinical experience is not a proxy for competence.

OBJECTIVE

To describe a mastery model of cardiac auscultation education and evaluate its effectiveness in improving bedside cardiac auscultation skills.

DESIGN

Untreated control group design with pretest and posttest.

PARTICIPANTS

Third-year students who received a cardiac auscultation curriculum and fourth year students who did not.

INTERVENTION

A cardiac auscultation curriculum consisting of a computer tutorial and a cardiac patient simulator. All third-year students were required to meet or exceed a minimum passing score (MPS) set by an expert panel at posttest.

MEASUREMENTS

Diagnostic accuracy with simulated heart sounds and actual patients.

RESULTS

Trained third-year students (n = 77) demonstrated significantly higher cardiac auscultation accuracy compared to untrained fourth year students (n = 31) in assessment of simulated heart sounds (93.8% vs. 73.9%, p < 0.001) and with real patients (81.8% vs. 75.1%, p = 0.003). USMLE scores correlated modestly with a computer-based multiple choice assessment using simulated heart sounds but not with bedside skills on real patients.

CONCLUSIONS

A cardiac auscultation curriculum consisting of deliberate practice with a computer-based tutorial and a cardiac patient simulator resulted in improved assessment of simulated heart sounds and more accurate examination of actual patients.

To think is good: querying an initial hypothesis reduces diagnostic error in medical students

PURPOSE

Most diagnostic errors involve faulty diagnostic reasoning. Consequently, the authors assessed the effect of querying initial hypotheses on diagnostic performance.

METHOD

In 2007, the authors randomly assigned 67 first-year medical students from the University of Calgary to two groups and asked them to diagnose eight common problems. The authors presented the same primary data to both groups and asked students for their initial diagnosis. Then, after presenting secondary data that were either discordant or concordant with the primary data, they asked students for a final diagnosis. The authors noted changes in students' diagnoses and the accuracy of initial and final diagnoses for discordant and concordant cases.

RESULTS

For concordant cases, students retained 84.2% of their initial diagnoses and were equally likely to move toward a correct as incorrect final diagnosis (6.9% versus 8.9%, P = .3); no difference existed in the accuracy of initial and final diagnoses: 85.9% versus 84.0% (P = .4). By contrast, for discordant cases, students retained only 23.3% of initial diagnoses, change was almost invariably from incorrect to correct (76.3% versus 0.4%, P < .001), and final diagnoses were more accurate than initial diagnoses: 80.7% versus 4.8% (P < .001). Overall, no difference existed in the accuracy of final diagnoses for concordant and discordant cases (P = .18).

CONCLUSIONS

These data suggest that querying an initial diagnostic hypothesis does not harm a correct diagnosis but instead allows students to rectify an incorrect diagnosis. Whether querying initial diagnoses reduces diagnostic error in clinical practice remains unknown.

Two-year skill retention and certification exam performance after fundamentals of laparoscopic skills training and proficiency maintenance

BACKGROUND

The purpose of this study was to determine 2-year performance retention and certification exam pass rate after completion of a proficiency-based fundamental laparoscopic skills (FLS) curriculum and subsequent interval training.

METHODS

Surgery residents (postgraduate year [PGY]1-5, n = 91) were enrolled in an Institutional Review Board approved protocol. All participants initially underwent proficiency-based training on all 5 FLS tasks. Subsequently, available residents were enrolled every 6 months in an ongoing training curriculum that included retention tests on tasks 4 and 5, with mandatory retraining to proficiency if the proficiency levels were not achieved. The final retention test included the actual FLS certification examination for PGY4-5 trainees.

RESULTS

A 96% participation rate was achieved for all curricular components during the 2-year study period (PGY3-5, n = 33). Skill retention at retention 1-4 was 83%, 94%, 98%, and 91% for task 4 and 85%, 95%, 96%, and 100% for task 5, respectively. All PGY4-5 (n = 20) residents passed the FLS certification examination, achieving 413 +/- 28 total score on the skills portion (passing score > or =270) and demonstrating 92% retention for all 5 tasks.

CONCLUSION

Proficiency-based training with subsequent ongoing practice results in a very high level of skill retention after 2 years and uniformly allows trainees to pass the FLS certification examination.

Medical education research as translational science

Research on medical education is translational science when rigorous studies on trainee clinical skill and knowledge acquisition address key health care problems and measure outcomes in controlled laboratory settings (T1 translational research); when these outcomes transfer to clinics, wards, and offices where better health care is delivered (T2); and when patient or public health improves as a result of educational practices (T3). This Commentary covers features of medical education interventions and environments that contribute to translational outcomes, reviews selected research studies that advance translational science in medical education at all three levels, and presents pathways to improve medical education translational science.

Do prior knowledge, personality and visual perceptual ability predict student performance in microscopic pathology?

OBJECTIVES There has been long-standing controversy regarding aptitude testing and selection for medical education. Visual perception is considered particularly important for detecting signs of disease as part of diagnostic procedures in, for example, microscopic pathology, radiology and dermatology and as a component of perceptual motor skills in medical procedures such as surgery. In 1968 the Perceptual Ability Test (PAT) was introduced in dental education. The aim of the present pilot study was to explore possible predictors of performance in diagnostic classification based on microscopic observation in the context of an undergraduate pathology course. METHODS A pre- and post-test of diagnostic classification performance, test of visual perceptual skill (Test of Visual Perceptual Skills, 3rd edition [TVPS-3]) and a self-report instrument of personality (Big Five Personality Inventory) were administered. In addition, data on academic performance (performance in histology and cell biology, a compulsory course taken the previous year, in addition to performance on the microscopy examination and final examination) were collected. RESULTS The results indicated that one personality factor (Conscientiousness) and one element of visual perceptual ability (spatial relationship awareness) predicted performance on the pre-test. The only factor to predict performance on the post-test was performance on the pre-test. Similarly, the microscopy examination score was predicted by the pre-test score, in addition to the histology and cell biology grade. The course examination score was predicted by two personality factors (Conscientiousness and lack of Openness) and the histology and cell biology grade. CONCLUSIONS Visual spatial ability may be related to performance in the initial phase of training in microscopic pathology. However, from a practical point of view, medical students are able to learn basic microscopic pathology using worked-out examples, independently of measures of personality or visual perceptual ability. This finding should reassure students about their abilities to improve with training independently of their scores on tests on basic abilities and personality.

"Could I add something?": Teaching communication by intervening in real time during a clinical encounter

Supervising learners as they communicate often places faculty preceptors in a classic educational dilemma. What should a preceptor do when the learner is not communicating well and is not asking for help? What usually happens, in the authors' experiences, is that the preceptor decides at some point that she or he cannot stand the situation anymore-then interrupts the learner and takes over the conversation. Interrupting in this way, however, comes at the cost of undermining the learner. Thus, the authors have developed an alternative teaching strategy designed for communication tasks such as giving serious or bad news. In the strategy recommended here, the preceptor sets up the possibility that he or she may intervene in the encounter. If the preceptor does intervene, he or she explicitly hands the conversation back to the learner and afterwards debriefs with the learner. The authors designed this strategy to decrease the risk to the patient while maximizing learning for the learner. This strategy offers preceptors a way to teach communication skills more effectively in clinical settings using intentional goal setting with learners, careful observation of the encounter, intervention when the conversation is not going well, and reflective feedback for the learner based on the learner's goals.

Higher surgical training in ophthalmology: trends in cumulative surgical experience 1993-2008

INTRODUCTION

Recent years have seen significant changes in the provision surgical training for ophthalmology. The aim of this study is to establish the patterns in long-term trends of cumulative surgical experience of ophthalmology trainees in the United Kingdom.

MATERIALS AND METHODS

Data were obtained from the department of training and education at the Royal College of Ophthalmologists (RCOphth). The cumulative surgical experience of all ophthalmology higher surgical trainees attaining accreditation, CCST, or CCT between 1993-2001 and 2005-2008 was included for descriptive analysis.

RESULTS

Cumulative cataract surgical experience per trainee has been relatively stable at levels between 500 and 600 for most years. The cumulative experience vitreoretinal and corneal graft surgery have historically been low with a large outlier effect, although trends demonstrate a decrease in the median numbers of procedures. Squint surgery has seen a downward trend with a decrease in the median numbers from 121 in 1993 to 43 in 2008. Oculoplastics procedures demonstrate a decrease in overall numbers from 46 in 1993 to 15 in 2001. A jump from 2005 coincides with changes in the definition of what is counted as an oculoplastics procedure. The role of the RCOphth in legislating minimum levels of experience has had an impact on the data distribution manifest by the truncation of the inferior quartile of many of the dataspreads.

DISCUSSION

These data demonstrate that although the cumulative experience of cataract surgery for trainees has remained stable, there has been a reduction in the median numbers of subspecialty procedures performed over the past 15 years.

Expertise

The study of expertise is based on the premise that experts in different domains follow a similar path of acquisition and development. This article distinguishes two research approaches to the study of expertise. The traditional approach assumes a steady progression from novice to expert as a function of training as well as years of experience often without measures of reproducible skill. A second and more recent one focuses on the identification of individuals with reproducibly superior performance for representative tasks that capture expertise in the domain. The focus of this review is on the latter, namely the expert-performance approach. The article describes how superior performance can be captured by standardized tasks, and how analyses of that superior performance can identify superior abilities, cognitive mechanisms, and physiological adaptations. The last part of the article reviews how deliberate practice and training can lead to the acquisition of complex mechanisms and physiological adaptations, which in turn can explain the experts' attained superior performance. The review is concluded with a discussion of future directions of studies of expert performance and the challenges in understanding the development of general abilities and the motivation to engage in sustained daily deliberate practice. Copyright © 2010 John Wiley & Sons, Ltd. For further resources related to this article, please visit the WIREs website.

What do physicians gain (and lose) with experience? Qualitative results from a cross-national study of diabetes

An empirical puzzle has emerged over the last several decades of research on variation in clinical decision making involving mixed effects of physician experience. There is some evidence that physicians with greater experience may provide poorer quality care than their less experienced counterparts, as captured by various quality assurance measures. Physician experience is traditionally narrowly defined as years in practice or age, and there is a need for investigation into precisely what happens to physicians as they gain experience, including the reasoning and clinical skills acquired over time and the ways in which physicians consciously implement those skills into their work. In this study, we are concerned with 1) how physicians conceptualize and describe the meaning of their clinical experience, and 2) how they use their experience in clinical practice. To address these questions, we analyzed qualitative data drawn from in-depth interviews with physicians from the United States, United Kingdom, and Germany as a part of a larger factorial experiment of medical decision making for diabetes. Our results show that common measures of physician experience do not fully capture the skills physicians acquire over time or how they implement those skills in their clinical work. We found that what physicians actually gain over time is complex social, behavioral and intuitive wisdom as well as the ability to compare the present day patient against similar past patients. These active cognitive reasoning processes are essential components of a forward-looking research agenda in the area of physician experience and decision making. Guideline-based outcome measures, accompanied by underdeveloped age- and years-based definitions of experience, may prematurely conclude that more experienced physicians are providing deficient care while overlooking the ways in which they are providing more and better care than their less experienced counterparts.